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EVELYN a PEARCE 


For many years Senior Nursing Tutor to the Middlesex Hospital, 
formerly Sister Tutor, Fazakerley Hospitals and Sanatorium, Brown- 
low Hill Hospital, Liverpool, and the Shropshire Orthopaedic Hospital; 
State Registered, General and Fever; State Certified Midwife; Ortho- 
paedic Cert., Baschurch; Sanitary Science, Liverpool; Masseuse, Medical 
Gymnast; Teacher’s Cert., C.S.M.M.G.; Member of the General 
Nursing Council for England and Wales and for many years Examiner 
for the Council; Examiner in Fever Nursing and Epidemiology for the 
Diploma in Nursing, London University, and in General Nursing for 
the Diploma of Leeds University. 


books by Evelyn C, Pearce 

★ 

MEDICAL AND NURSING DICTIONARY AND ENCYCLOPAEDIA 

A TEXTBOOK OF ORTHOPAEDIC NURSING 

ANATOMY AND PHYSIOLOGY FOR NURSES 

FEVERS AND FEVER NURSING 

A COMPLETE HANDBOOK OF HYGIENE IN 
QUESTIONS AND ANSWERS 

INSTRUMENTS, APPLIANCES AND THEATRE TECHNIQUE 



A GENERAL TEXTBOOK 
OF NURSING 


a comprehensive guide 


by 

EVELYN C. PEARCE 


NINTH EDITION 


FABER AND FABER LTD 
24 Russell Square 
London 

1945 



First published in IS137 
Second edition, October rggS 
Third edition, October iQtSS 
Fourth edition, Se^ember 1940 
Fifth edition, June 1941 
Sixth edition, January x^4S 
Seventh edition, September 194s 
Eighth edition, April 1943 
Jyfinth Edition, 1945 
By Faber and Faber, JLimited 
Printed in Great Britain by 
Purnell & Sons, Etd. 
Paulton, Somerset and London 


Fhis book is produced in complete coriformity 
with the authorized economy standards 



Preface to the First Edition 


] n writing this book for nurses it has been my endeavour to provide 
one which is sufficiently comprehensive to enable the student to 
- find in it the introduction to nursing she needs on entering hospital, 
a useful book of reference as she works In one department of the hospital 
or other and the information she requires in order to pass the Hospital 
and State Examinations in the different branches of nursing subjects 
included in the curriculum. 

The information I have been able to give is largely derived from 
personal experience in the care of the sick and in the teaching of nurses. 
I desire to express my gratitude to my teachers first of all, then to those 
whose books and articles I have read and also to many friends who have 
helped me by advice and kind criticism. I should like to thank them all 
individually, but space does not permit. Will they please accept my 
thanks for helping me to help others? 

I have the greatest pleasure in expressing my gratitude to Sister 
Marjorie Wenger for help in arranging the illustrations, to Mr. B. D. H. 
Watters for his able photography and to Mr. C. W. Stewart of Messrs. 
Faber and Faber for his co-operation and assistance. I acknowledge 
also my indebtedness to Miss G. E. Davies, the Registrar of the General 
Nursing Council, for permission to make use of State Examination 
question papers. 

Evelyn C. Pearce. 

Match 31st j 


5 



Preface to the Ninth Edition 


I t has been found necessary, in order to economize paper, to separate 
the photographs from the text. These will be found in groups through- 
- out the book in positions where it is most convenient to include them. 
Both the publishers and I regret the necessity for this step which I can 
assure my readers has only been taken after the most careful deliber- 
ation and is introduced as a temporary measure during the shortage of 
paper. 

A number of alterations have been made to this edition in order to keep 
the book quite up to date, A new chapter on Sanatorium Nursing has been 
added and the notes in the Surgical Section on Thoracic Surgic^ Nursing 
have been amplified. 

EVELYN C. PEARCE. 

September y 1944. 


6 



Contents 


Section i • General and Special Nursing Measures and 
Procedures 

INTRODUCTORY page 1 5 

1 RECEPTION and ADMISSION OF A PATIENT IQ 

The reception and admission of a patient — Observations to be made 
on a patienVs condition — Examination of a patient — Discharge and 
transfer of patient 

2 TEMPERATURE, PULSE AND RESPIRATION 3I 

Temperature : The variations of temperature in health and disease 
— Methods of taking the body temperature — Notes on the febrile state 
— The stages of a rigor. Pulse : The variations of the pulse in health 
and disease — Abnormal pulses — Blood pressure — Respiration: 
Variations of respiration in health and disease — Abnormal respira^ 
lions — Dyspnoea and cyanosis 

3 THE TOILET OF THE PATIENT 45 

Bathing adult patients and infants — Care of the mouth — Care of 
the he^ — Prevention of bedsores — Giving bedpans and urinals 

4 OBSERVATIONS OF EXCRETA .AND DISCHARGES AND COLLEC- 

TION OF SPECIMENS 58 

The characteristics of normal urine and its variations in health and 
disease — The testing of urine — Characteristics of normal faeces with 
variations in health and disease — Collection and disposal of sputum 
and observations — Types of vomit; care of a patient when vomiting — 

Vaginal discharges^ observations and nursing care — The collection 
of specimens of urine^ faeces ^ sputum and vomit; of pus^ fluids and 
secretions and of blood 

5 THE CARE OF MATERIALS AND APPLIANCES USED IN MAKING 

BEDS 72 

Hospital beds and bedding — Removing stains from materials — 

Care of rubber goods — Making beds: moving patients in bed — 

Special types of beds — The use of bedblocks, cradles^ rests and 
tables, air and water beds and pillows 

6 POSITIONS USED IN NURSING 86 

The positions described are: — Supine — Prom — Semirecumbenl — 
FoudePs — Left lateral — Sims's semiprone — Litkotorr^ — Tren^ 
delenburg's — Rose's — Genu^pectoral — Orthopnoeic — Hyperex^ 
tension — Nelson's bed 


7 



8 


CONTENTS 


7 LOCAL APPLICATIONS page 90 

Fomentations and stupes — Applications of coldy icebag^ cold 
compress^ evaporating dressings Leiter^s coil^ ice poultice — Poultices 
and plasters: antiphlogistincy linseed^ mustard^ charcoal and starchy 
mustard plaster^ belladonna and opium plasters — Liniments — Oint- 
ments and glycerines — Application of a leech — Counterirritants: 
rubefacientSy vesicants and cupping 

8 GENERAL APPLICATIONS 1 1 I 

Applications of heat — Hot packsy vapour and hot air baths — 

Radiant heat baths y hot baths and hot sponging — Warm baths and 
medicated baths — Aerated and foam baths — General treatments for 
the reduction of temperature — Tepid and cold sponging y exposed 
sponging — Brandt's bath — Ice cradling — Affusion 

9 THE USE OF ENEMATA AND SUPPOSITORIES 1 28 

The administration of an enema — The use of a flatus tube — 
Varieties of enemata — Giving enemata to babies and infants — 
Suppositories 

10 IRRIGATION, LAVAGE, DOUCHING AND CATHETERIZATION 1 35 

Gastric lavage — High colonic irrigation — Catheterization and 
bladder irrigation and drainage — Vanned douching 

I I ARTIFICIAL FEEDING AND THE ADMINISTRATION OF FLUID 

AND BLOOD TRANSFUSION I 93 

Methods of artificial feeding — Channels for the adminutration of 
fluid — Blood transfusion: direct and continuous — The grouping of 
blood 

12 ASPIRATION, AND DRAINAGE OF BODY CAVITIES 202 

Aspiration of the pleural cairAy and the pericardial sac — Tapping 
the abdomen — Drainage of the subcutaneous tissue — Lumbar punc- 
ture and cisternal puncture 

13 SOME INVESTIGATIONS AND TESTS 208 

X-ray examination of the alimenlary tract — The use of lipiodol in 
X-ray examination — Examination of the function of the gallbladder — 
Examination of the function of the kidneys — Examination of the 
urinary bladder — Examination of the sigmoid colon — Gastric 
analysis — Glucose tolerance test 

14 THE APPLICATION OF SPLINTS, PLASTER OF PARIS EX- 

TENSIONS AND STRAPPING 220 

Types of splints — Plaster of paris — The use and application of 
extension — Skeletal traction — Splint and plaster sores — Closed 
plaster method— Application of strapping 

15 BANDAGES AND BANDAGING 244 

Types of bandages — Materials used in bandaging — Mules for the 
application of a roller bandage — Examples of bandaging — Triangu^ 
lot bandaging 



CONTENTS 


9 


Section 2. The Feeding of Adult Patients and Infants and 
Elementary Dietetics 

16 FOOD AND FEEDING OF ADULT PATIENTS page 261 

Classification of foods — The use of proteins^ carbohydrates and fats — 

The value of water to the body — The use of salts ^ vegetables and 
fruits f milk and eggs — The preparation of milk for invalid feeding — 

Serving food to patients — The administration of fluid diet, 

I 7 THE FEEDING OF INFANTS 273 

Composition of milk — The preparation of milk for infant feeding — 
Precautions in feeding — Weaning an infant 

18 ELEMENTARY DIETETICS 278 

Diet in diabetes^ nephritis^ cardiac conditions^ malnutrition y peptic 
ulceTy hypochlorhydria and hyperchlorhydriay jaundicCy constipation 
and colitis — Calcium and iron diets — Diet in deficiency diseases 


Section 3. The Administration of Drugs and Medicines and 
Elementary Materia Medica. Poisons and Poisoning 

1 9 ADMINISTRATION OF MEDICINES AND DRUGS page 292 

The origin and dosage of drugs — Idiosyncrasy and intolerance — 
Weights and measures — Modes of preparation of drugs — Classifica^ 
tion of drugs — The prescription — The safe custody of medicines and 
drugs — Rules for giving medicine — Modes of administration of 
drugs — Inhalations y including administration of oxygen — The use of 
sera and vaccines — Chemotfmapy 

20 POISONS, AND THE TREATMENT OF POISONING 332 

Dangerous Drugs and Poisons Acts — Poisoning and its treatment — 
fJxamples of poisonings including gas poisoning 


Section 4. Medical Conditions and Diseases and their 
Treatment and Nursing 

INTRODUCTORY page 336 

The obsmation of ^ptom — Insomnia, the importance of rest and 
sleep in the treatment of disease — Varieties of pain, including types of 
colh — The manifestations of indigestion as a symptom of disease — 
Delirium 



10 


CONTENTS 


22 DISEASES AND DISORDERS OF HEART AND ORGANS OF 

CIRCULATION pa^ 

Pericarditis^ endocarditis^ myocarditis — Congenital heart disease^ 
functional heart disease — The symptoms ^ treatment and nursing of 
cases of heart disease — Cardiac syncope — Angina pectoris — Coronary 
thrombosis and embolism — Cardiac asthma — Diseases of the blood 
vessels — aneurysm^ arteriosclerosis^ arteritis and atheroma — High 
blood pressure — Low blood pressure — Diseases of the blood — 
anaemia^ diseases of the white cells — splenic anaemia^ leucocytosis and 
leukaemia^ haemophilia^ purpura^ polycythaemia — Diseases of the 
lymphatic system — adenitis^ lymphangitis^ and lympkadenoma 

23 DISEASES AND DISORDERS OF THE ORGANS OF RESPIRATION 

Catarrhal conditions of the respiratory tract: pharyngitis^ laryngitis^ 
tracheitis and bronchitis — Emphysema — Bronchiectasis — Asthma — 
Pneumonia — Broncho-pneumonia — Pleurisy — Empyema — Haemop- 
tysis — Pulmonary embolism 

24 DISEASES AND DISORDERS OF THE ORGANS OF DIGESTION 

Dyspepsia — Peptic ulcer — Haematemesis — Inflammatory conditions 
of the alimentary tract — stomatitisy gastritisy enteriiiSy colitiSy 
diverticulitis and epidemic diarrhoea — Diarrhoea and constipation — 
Worms — Pyloric stenosis — Hirschsprung's disease — Visceroptosis — 
Diseases of the liver and gallbladder— jaundice y cholecystitis^ 
cirrhosis of livery liver abscess y acute yellow atrophy 

25 DISEASES AND DISORDERS OF THE ORGANS OF THE URINARY 

TRACT 

Nephritis y acute and chronic — Uraemia — Infections of the urinary 
tracly pyelitis and cystitis — Disorders of micturition 

26 DISEASES AND DISORDERS OF THE NERVOUS SYSTEM 

Introduction — Symptoms of an upper and lower neurone lesion — 
Hemiplegia — Paraplegia — Disseminated sclerosis — Infantile 
paralysis — Bell's palsy — Neuritis — Syphilis of the nervous system — 
cerebral syphilisy locomotor ataxiay general paralysis of the insane — 
Inflammation of the brain and meninges — meningitis y encephalitis 
lethargica — Infections of the spinal cord — transverse myelitis — 
Functional disorders — Neuralgia — Hysteria — Paralysis agitans — 
Chorea — Anorexia nervosa — Psychoses and Neuroses — Fits and con- 
vulsions— Epilepsy— Hysterical jit— Apoplexy— Coma 

27 DISEASES AND DISORDERS OF THE ENDOCRINE GLANDS 

Introduction The thyroid glandy cretinismy myxoedemOy and 
Graves's disease— The suprarenal glandsy Addison's disease — TJie 
parathyroids y tetany and von Recklinghausen's disease — The pituitasy 
glandy fuTictions of anterior and posterior lobes y Simmonds's disease — 
The ovarian and testical secretions — ITie intrinsic factor of Castle — 
The pancreaSy diabetes 



CONTENTS 


II 


28 ACUTE INFECTIONS page 442 

Influenza — Acute rheumatism — Typhoid fever — Undulant fever — 
Dysentery — Cholera— Efysipelas — Anthrax ^ — Tetanus — Glandular 
fever — Malaria 

29 LOUSE-BORNE DISEASES 459 

Introduction — Epidemic typhus fever — Epidemic relapsing fever 
— Trench fever 

30 THE NURSING CARE OF INFECTIOUS DISEASES (fEVER NURSINO) 462 

Introduction — Methods of isolation — General nursing care — Note on 
cross-infection^ return case and the administration of quarantine — 
Diphtheria — Scarlet fever — Measles and rubella — Whooping cough 
— Mumps — Smallpox and chickenpox — Vaccinia 

31 PULMONARY TUBERCULOSIS (SANATORIUM NURSING) 481 

Introduction — Predisposing factors — Sources of infection — Varieties 
— Changes in the tissues — Resistance to infection — Preventive 
measures — Diagnostic procedures — Modes of onset — Symptoms — 
Complications — Treatment and nursing — General ireatnunt — 

Special nursing care — Treatment for relif of distressing symptoms 
— Collapse therapy— Monaldi drainage — Hints on hygiene to nurses 

32 EXAMPLES OF DISEASES OF THE SKIN 498 

Introduction — Characteristics of skin lesions — Examples of non- 
specific conditions: Urticaria — Eczema — Psoriasis — Diseases due to 
microbic infection^ vegetable fungi and animal parasites — Impetigo — 
Pemphigus — Lupus— ^eborrhoea — Sycosis — Scabies — Pediculosis — 
Ringworm — Athlete's foot — Favus — Herpes 


Section 5. Gynaecological Conditions and their Treatment 
and Nursing Care. Venereal Diseases. A Short Account 
of Pregnancy, Antenatal Care and the Puerperium 

33 OYNAECOLOOICAC NURSINO, PREPARATION FOR OPERATION 

AND POST-OPERATIVE CARE page 508 

Introduction — Common gynaecological operations — J^otes on prepara- 
tion and post-operative care in vaginal and abdominal cases — Exam- 
ination of a patient and some special treatments including the toilet of 
the vulva, insertion of tampons, packing the vagina and the use of 
pessaries 

34 INFLAMMATORY CONDITIONS, DISEASES AND DISORDERS OF 

THE FEMALE GENERATIVE ORGANS 52O 

Ascending ir^ammaiion of the genital tract: vulvitis, vaginitis, 
cervicitis, endometritis and salpingitis — Ruptured ectopic gestation — 
Disorders of the uterus: amenorrkoea, dysmenorrhoea, menorrhagia 
and metrmhe^a — Displacements of the uterus — Diseases of the 
uterus {including cancer) and diseases of the ovaries 



12 


CONTENTS 


35 A SHORT OUTLINE OF VENEREAL DISEASES AND THEIR MAN- 

AGEMENT 535 

A short account of syphilis and its treatment — The mode of infection 
in gonorrhoea^ acute and chronic stages^ treatment — A note on soft 
sore 

36 PREGNANCY, ANTENATAL CARE, AND THE PUERPERIUM 543 

Ovulation^ menstruation and fertilization — The symptoms and signs 
of pregnancy — Antenatal care — The toxaemias and complications of 
pregnaruy — iMbour and the puerperium — Puerperal sepsis — Nursing 
care in septicaemia 

Section 6, Surgical ’ Nursing and Elementary Surgical 
Technique 

INTRODUCTORY page 556 

37 INFECTION INFLAMMATION HAEMORRHAGE ULCERS 

TUMOURS AND CYSTS 557 

Surgical infection — Gas gangrene — Infammation: symptoms^ ter^ 
minations and treatment — Haemorrhage: causes of bleedings general 
classification^ symptoms associated with bleedings means used in 
treatment — Ulcers — Tumours and cysts: Classification of tumours^ 
differences between simple and malignant tumours 

38 INJURIES TO SOFT STRUCTURES 575 

Burns and scalds — IVounds, contusions and bruises — Crush syndrome 
— The healing of wounds — Care of an infected wound — Injuries to 
tendon, muscle and nerveSiings and bites-Foreign bodies in the tissues 

39 INJURIES TO BONES AND JOINTS 595 

Fractures: predisposing and exciting causes, varieties of fracture, 
symptoms and signs, healing and repair, complications — Fractures of 
the skull: symptoms of fracture of the base, irealrnent and nursing — 
Concussion, compression and cerebral irritation: observation, treats 
meni and nursing care — Fractures of the spine: signs and symptoms, 
treatment and nursing — Fractures of the pelvis — Injuries to joints: 
sprains and dislocations 

40 OPERATION TECHNIQUE, INCLUDING THE PREPARATION FOR 

AN OPERATION IN A PRIVATE HOUSE. EXAMPLES OP 
ANAESTHESIA AND THE PREPARATION OF THE PATIENT FOR 
ANAESTHESIA AND FOR OPERATION, INCLUDING PREPARA- 
TION OF THE SKIN 607 

Preparation of hands — Theatre dress — Sterilization of instrumerUs, 
utensils and dressings — Lotions — Antiseptic powders and pastes — 
Sutures, ligatures and surgical needles — Preparation for an operation 
in a private house — Use of anaesthetics: general, local, regional, 
splanchnic, spinal and sacral — Use of basal narcotics with notes on 
post-anaesthetic care — Preparation of the patient for operation, in^ 
eluding preparation of the skin 



CONTENTS 


13 


41 POST-OPERATIVE TREATMENT AND NURSING CARE, INCLUD- 

ING THE MANAGEMENT OF A SURGICAL DRESSING page 636 

Past^operative nursing: position^ prevention and treatment of shocks 
relief of discomforts following abdominal operations — Observations 
to be included in the nurse* s report on the patient — Diet after abdom-^ 
inal operations — Action of the bowels — Care of the wound — Com- 
plications following abdominal operations — Management of a 
surgical dressing 

42 COMMON GENERAL SURGICAL CONDITIONS TREATED BY 

OPERATION, INCLUDING SOME POINTS IN THE PREPARATION 
AND POST-OPERATIVE CARE 654 

Acute abdominal conditions: ir^ammation^ obstruction and perfora- 
tion — Appendicitis: symptoms^ post-operative nursing — Operations 
on the stomach — Hernia — Haemorrhoids — Resection of colon^ colos- 
tomy and perineal excision of rectum with notes on post-operative 
nursing — Thyroidectomy: preparation and post-operative nursing 
care — Operations on the breast and post-operative nursing care — 
Operations on the thorax — Amputation of a limb 

43 COMMON SURGICAL CONDITIONS OF THE GENITO-URINARY 

TRACT, INCLUDING POINTS IN THE PREPARATION AND 
POST-OPERATIVE CARE 675 

Surgical conditions of kidn^s and bladder: pyelitis^ acute suppurative 
nephritisy stone in kidney — Operations on the kidney — Stone in the 
bladder — Operations on the bladder — Enlargement of the prostate 
glandy special measures in preparation for operation and post-opera- 
tive nursing 

44 AFFECTIONS OF THE EAR, NOSE AND THROAT — HARELIP AND 

CLEFT PALATE — NURSING CARE 721 

Examination of the ear — Syringing an ear — The insertion of drops — 
Affections of the ear: the presence of a foreign body^ otitis media and 
mastoiditis — Affections of the nose — Affections of the throat — Ton- 
sillectomy — Intubation — Tracheotomy — Laryngectomy — Harelip 
and cleft palate 

45 AFFECTIONS OF THE EYE AND THEIR NURSING CARE 735 

Examination of the ^e — Affections of the lids: stieSy cystSy blepharitisy 
lachrymal obstruction — Conjunctivitis: pink eyCy purulent and gonor- 
rheal conjunctivitis — Affections of the cornea and iris: comeal ulcevy 
keratitis y arcus senilis y iritis — Affections of the lens: cataracty prepara- 
tion and post-operative nursing — Glaucoma — Detached retina — 
Enucleation of the eye 

46 THE NURSING CARE OF CASES OF SURGERY OF THE BRAIN 754 

Degrees Ojf unconsciousness — The nursing of an unconscious patient — 
Preparation for an operation On the brain and the post-operative 
nursing care 



CONTENTS 


47 ORTHOPAEDIC NURSING 759 

Classification of deformities — The treatment and care of cases met 
with in an orthopaedic unit^ including: Common congenital deformi-> 
ties — Flatfoot and other conditions of the feet — Deformities of the 
vertebral column — Deformities due to rickets^ to diseases of the centred 
nervous system and to contractures 

48 SURGICAL TUBERCULOSIS 779 

Infection by the tubercle bacillus— Changes in the tissues — A tuber^ 
culous abscess — Tuberculosis of glands — Tuberculosis of bones and 
joints — Tuberculosis of the genito-urinary system 

49 RHEUMATIC AFFECTIONS OF JOINT AND MUSCLE 784 

The symptoms and treatment of arthritis— Gold therapy — Muscular 
rheumatism 

50 THE NURSING OF CANCER CASES 789 

The care and nursing of cancer cases — Notes on the treatment of can-- 
cer by radium and X-ray therapy 

51 THE NURSING OF THE DYING AND THE CARE OF THE DEAD 795 

Deathy the duties of doctor and nurse — The mental and physical 
state of a dying patient — Relief of distressing symptoms — Care of the 


body after death, last offices 

APPENDIX l: FIRST AID FOR GAS CASUALTIES 80I 

APPENDIX II ; TABLE OF VITAMINS 804 

APPENDIX III: EXAMINATION QUESTIONS 806 

index 819 



Section i 


General and Special Nursing Measures and 
Procedures 


Introductory 

A hospital is a place in which the sick are treated and nursed. Some 
of our large hospitals are nursing schools and are attached to 
k medical schools; the nurses learn to nurse and the medical students 
are given opportunities for the clinical study of medicine and its allied 
sciences. The girl who wishes to be a successful nurse will never, for one 
moment, forget that the only function of the hospital worth recording is — 
the cure and care of the sick. 

The girl who is attracted to nursing has the wellbeing of her fellow- 
men at heart, she wishes to do something, and be of some use in the world 
and she may never forget that those she has set out to help are her patients 
— the sick. She will soon learn that illness gives rise to abnormality; she 
will find many patients trying and many nursing duties unpleasant. She 
will also find that a busy ward sister, w'ho may be in charge of 20, 30 or 
even 40 sick persons, has both her mind and her hands full, and may not 
always have the time — in our present system — to explain exactly how she 
wants her ordcra carried out, nor the exact technique she would like 
adopted in any given nursing treatment. It is with the desire to help 
nurses to study and understand some of the procedures in use in hospital 
and to give a short account of a number of the conditions and diseases 
met, together with the nursing of these and the observations which should 
be made, thus rendering easier the work of a very busy rection of the com- 
munity, that this book has been written. 

When relatives bring a patient into hospital it is with mingled feelings 
they come, partly fear of the unknown, doubts as to how he will be 
received and treated, and hope that he can be cured or relieved. The 
patient himself also is fearful; the change from the most comfortable room 
his home could provide, to a large ward where he will lie in a bed sur- 
rounded by other ill patients requires courage to meet. The helplessness 
in being sick and in b<^, the knowledge that others will think for him and he 
will be in the hands of strangers to do their bidding — and the thought 
that these strangers may not understand him and his needs adds sufiTcring 
to his fears. So much aepends on the attitude of the nurse who receives 
him, since she by kindness and thoughtful sympathy can change the picture 
and dispel moat of the fears. She can make it clear by her interest and 
devotion that the hospital to which the patient has come is there for his 
benefit. A nurse who has sufficient imagination and sympathy to consider 
herself in the position of the patient, and also of his relatives, is the so-called 
horn nurse’. More recently she is being described as ‘psychologically 



1 6 INTRODUCTORY 

minded’ — which simply means that she is interested, and anxious to under- 
stand the workings of the human mind, that she is willing to learn how 
physical suffering reacts on the mind, disturbing the emotions and the 
will in such a way that the patient is not normal whilst he is ill, and that 
conversely, disorders of the mind, including depression, fear and states of 
anxiety, may produce symptoms of disease and that she realizes that, 
whatever may be the cause of his illness, the patient is in need of under- 
standing and sympathy and cannot for the time being be treated like a 
healthy robust person. A nurse with the gift of making her patients feel 
at home, and free from fear, inspires corfi dencc and provides an atmo- 
sphere of peace, serenity and security which is so important an adjunct to 
the relaxation of mind and body necessary for recovery from disease. 

But, in addition to being kind and sympathetic, the nurse who is 
interested will be quick to perceive the discomfort from which a patient 
may be suffering, even before he has had time to realize it. The following 
story is a fact which was repeated by a patient, and it illustrates the value 
of keen perception. A patient admitted for an operation on one eye was 
lying in bed with both eyes covered by bandage. The ward sister came to 
the bedside, called a probationer nurse and said, ‘Mr. is not comfort- 

able, nurse, we will make him so’. The slight work entailed proceeded, and 
in telling the story the patient remarked that when sister had finished he 
certainly was most comfortable but that although not at rest before he had 
not realized how uncomfortable he was, as he thought he was as comfort- 
able as was possible in the circumstances. 

The psychological factor in nursing may not be consciously appreciated 
by a nurse, yet as she goes about her routine duties she is constantly de- 
monstratir^ her reaction to these needs as cxampled in the delicacy with 
which she performs certain difficult duties; the patience and gentleness and 
tact used in persuading a patient to take his food or medicine; the confident 
attitude used in leading a patient to accept treatment. This is specially 
demonstrated when a nurse puts the bright side — the success to be expected 
— before a patient who is contemplating an operation or undergoing a 
general anaesthetic. In these and lots of other ways a nurse is constantly 
inspiring her patients with hopefulness, confidence and trust which result 
in relief from anxiety and consequent relaxation of mind; which after all 
is only applying the principles of psychology to the treatment of his 
condition. 

Suggestion in nursing is very helpful but it has to be used in a different 
way to suit each patient, as the need of each is intuitively recognized by 
the nurse. Nothing is more attractive than to watch a night nurse making 
her firat round at night. She turns a pillow here, tucks in the bedclothes 
there, feels the pulse of one and nods her approval at another and so on, 
with the result that she leaves behind her a more contented patient and 
consequently one more disposed to go to sleep. 

Nursing is hard work, demanding that all effort should be intelligent, 
since valuable effort would otherwise be wasted. Nurses are not in hospital 
only to do, but to think and to think first. The sort of discipline necessary 
in hospital lies in accomplishing good team work and not in blind obedi- 
ence. But loyalty to the orders and wishes of physicians, surgeons, matron 
and sisters is necessary, and obedience to the rules which have been made 
to safeguard human life is imperative. Such rules, for example, as those 
controlling the safe custody and the administration of dangerous drugs and 



INTRODUCTORY 


17 

the use of poisons in order to prevent mistakes and also the laws governing 
aseptic technique in order to avoid infection must be rigidly adhered to. 
That a nurse should be competent is essential, and to attain this it is neces- 
sary to aim at perfection in her work, for there are times when a human 
life may depend on perfection in carrying out some point of technique, 
or on promptness of decision and action. Work in the operating theatre, 
for example, calls for a high degree of conscientiousness. However skilled 
a surgeon may be the success of his work depends on the careful prepara- 
tion, by theatre sisters and nurses, of all the articles he may need. A 
theatre nurse must be so meticulously careful in practising the known rules 
of aseptic technique that she should be unable to make a mistake. 

After the first few months of hospital training the nurse should examine 
herself to see whether, for any reason, the duties of nursing are beginning 
to pall. This need not indicate any slackening of ideals; it may be due to 
the physical strain which nursing is — a tired body and aching feet making 
it difficult to concentrate on the needs of others. Apparent apathy may be 
due to lack of outside interest. Some nurses tend to make a hobby of their 
work. This is quite wrong. Nursing demands so much that it is essential 
for the nurse to have a variety of recreation — intellectual, social and sport- 
ing, in order to be able to bring the freshness necessary to put interest into 
her arduous work. 

If, however, the nurse finds, on examination, that her attraction to the 
work is lessening, she should give it up; it will require courage to make this 
acknowledgement to herself, but it is the only honest thing to do. Indiffer- 
ence can only produce second best, and nursing is a vital service. 

Florence Nightingale taught: ‘The very alphabet of a nurse is to be 
able to read every change which comes over a patient’s face, note every 
alteration of attitude, and every change of voice, without causing him 
the exertion of saying what he feels.’ She taught the importance of 
respecting confidences and never answering questions about a patient 
except to those who have a right to ask, the need for devotion to duty, 
and of respect for her own calling because ‘God’s precious gift of life 
is often placed in her hands.’ , 

The latest advances in Medical Science are brought to the bedside by 
the doctor; let the nurse see that her part is to provide, in full measure, 
the healing touch of human sympathy. The smallest service done to the 
lowliest possesses an eternal value. 

REHABILITATION 

Rehabilitation is the co-ordination of all the departments of a hospital 
to one common end, which is their raison d'etre — the care, cure, welfare 
and return to full health and normal occupation of the individual \^ ho 
presents himself, for the time being, as a patient. 

A scheme of medical rehabilitation should include, in addition to the 
medical, surgical and nursing resources of the hospital, the work of the 
almoners, research departments and laboratories where disease can be 
studied and aids to diagnosis provided, physiotherapy, radio-therapy, 
occupational therapy, hospital library, education, recreational facilities, 
canteen, follow up and after care, with vocational training in special cases. 

Nurses should be specially interested in rehabilitation, as they arc in 
the first line of advance and can do more than others to bring to the 



1 8 INTRODUCTORY 

patient just that help which he needs exactly when he needs it most. 
Hospital treatment is only a stage in recovery and rehabilitation begins 
when the patient is admitted. In taking the history of his illness the nurse 
gains some knowledge of his background, learns what his occupation is, 
realizes where the aim of all treatment lies for him, and henceforth she 
sees him where he wants to be — ^fully restored to health and back at his 
normal occupation. All her work is then directed towards this end. 

Social medicine is the term used to describe a study of the patient’s back- 
ground and environment. It is important to find out whether the con- 
ditions under which the patient has been living have contributed to his 
illness. This study is made in order to effect improvement in a known 
set of circumstances so that they shall not continue to be a source of 
breakdown in health, and to create good social conditions. 

The hospital almoner is specially trained to help with a patient’s personal 
and domestic diflSculties, study his environment and see how improve- 
ment can be carried into effect. Nurse and almoner should work hand 
in hand or as one sister aptly expressed it ‘hand in glove’. The actual 
treatment a patient receives in hospital is infinitesimal in comparison 
wath his welfare and happiness in the details of his entire life, and he 
cannot derive the benefit which should accrue from treatment unless he 
has the freedom from worry and anxiety which is the basis of relaxation 
of mind and body. 



Chapter i 

Reception and Admission of a Patient 

The reception and admission of a patient — Observations to be made on a patient* s 
condition — Examination of a patient— Discharge and transfer of patient 

junior probationer may quite early in her career be accosted at the 
doorway of her ward by a patient and his friends on his arrival at 
-L A. the hospital. He is not to know that she is not a very senior official, 
even the sister of the ward; she must therefore be prepared to meet him 
with smiling courteous dignity, receiving him like a hostess, listening care- 
fully to the questions he may put to her, and answering them with tact- 
ful consideration; then, inviting the patient and his friends to be seated 
while she informs the sister of the ward, who she may correctly say is 
prepared to receive and is expecting this patient, leaving him for a moment 
contentedly seated and waiting to be received by the sister who expects 
him. 

The nurse responsible for admitting the patient walks towards him with 
alacrity, pleased to see the patient for whom she has prepared the bed 
and whom she is expecting. She rapidly glances down the card he presents 
and gives him a smile of reassurance, calls him by name which she has 
learnt from the card, notes the diagnosis, and makes a rapid suiwey of the 
condition of the patient, by which she is enabled to determine whether 
he may remain seated for a few moments, or whether he should be put 
to bed immediately. 

'Fhc adrnisssion card contains particulars of the name, age, address of the 
patient, and his occupation, the name of the member of the honorary 
medical staff under whom he is to be admitted, the name and address 
of the patient’s private doctor, the diagnosis of the case, including re- 
marks on this, which may possibly have been made when the patient was 
examined in the Casualty Department before being sent to the ward, 
riie nurse makes a mental note of these and, observing the address, 
notices whether it is local or some distance away, and immediately 
inquires the sort of journey he had and when he last had anything to eat. 
As already stated, the condition of the patient will indicate whether he 
is to be put to bed immediately or not: for example, if he is a surgical case 
for operation next day he might have his temperature taken, then be 
given some food and afterwards be bathed in the bathroom before getting 
into bed; on the other hand, if the patient is at all ill or in pain, or suffering 
from any uncomfortable symptoms, he should be put to bed at once. In 
this case it is usual to ask the relatives to wait until the patient is in bed; 
in some hospitals the relatives take the patient’s clothes away with them, 
fhey might go to the bedside and speak to the patient before leaving. 

There are certain questions which it is practically always advisable to 
ask the I'elativcs. Make sure that the address on the admission slip is where 
they are staying; ask whether they are at home all day, or out at business; 
fr the latter case get the business address, the hours they will be there 
‘Hid the telephone number. Then ask the name of the nearest police 


19 



20 RECEPTION AND ADMISSION OF A PATIENT 

Station, informing them that this is required in case untoward symptoms 
should occur with rapidity, when the police will undertake to deliver a 
message day or night, in the event of there being no telephone in the house. 
If the patient has come in for operation, get their si^ed permission for 
this to be performed. It is also advisable to ask questions of the relatives 
which could not reasonably be put to the patient: for example, if the 
patient is being admitted to the eye department, the condition of his 
mental health is qf vital importance, as he will be subjected to mental strain 
owing to the necessity of lying still with his eyes covered and being made 
so helpless that he has to be fed. In most cases it is a very good plan to find 
out if the patient is occasionally subject to attacks of any kind, such as 
vomiting, depression or fits, and also whether he has ever had a nervous 
breakdown. 

It will be very reassuring to the relatives if the nurse asks for little 
intimate details about the patient, such as the position he likes to sleep in, 
how many pillows he is used to, whether he likes to sleep in sheets or 
blankets, how he sleeps, whether he is troubled by having to pass urine 
in the night, whether he likes a cup of tea when he wakes, and the condition 
of his appetite, including any special likes or dislikes. She might also ask 
the religion of the patient, and whether any minister has been visiting 
him, explaining, if so, that such visits can be continued, at the same time 
informing the relatives that if the patient wishes he can be visited by the 
attending chaplain of whatever denomination he belongs to. 

She should tell the relatives which are the visiting days, give them the 
necessary cards of admission, and ask them to inquire later on in the day 
as to the patient's comfort, giving them the hospital telephone number. 
They might also be informed of any little delicacies they may bring the 
patient. If the hospital does not provide clothing and towels for the patient, 
the relatives should be informed as to what is necessary; if, however, this 
information was included when the patient was written for, the nurse 
should see that the necessary articles have been brought. These usually 
include personal bed attire, at least two sets of bath and face towels; 
toilet accessories — soap, flannel, sponge, toothbrush and paste, brush and 
comb. If the relatives are to take the patient's clothes home (see below) the 
nurse should go carefully through these and make a list of any articles 
that are retained for his use whilst in hospital. 

The house doctor should be notified of every admission as soon as 
practicable, giving him the diagnosis, time of admission, temperature, 
pulse and respiration rate, and any urgent special symptoms noticed. 

The bed card should be made out, and the temperature, pulse and 
respiration rate charted; if possible a specimen of urine should be obtained 
and tested and the specimen kept until the house doctor has made his 
first visit, in case he wishes to inspect it. 

Patient’s clothing. If the patient is well enough when he is admitted, 
the nurse should check his belongings over with him, imless this is done 
with his relatives. If they arc taken home she should get a receipt for them. 
Should the patient be brought in unaccompanied by any friend or relative, 
and be in a state in which he is not fit to be troubled, or for any other 
reason is unable to check his own belongings, the nurse should make a list 
of these, inspect them for cleanliness, and the presence of vermin, in which 
case they might have to be disinfected and washed. She should then fold 



RECEPTION AND ADMISSION OF A PATIENT 21 

them carefully and put them away in a cupboard, labelling the parcel 
with the name of the patient, the name of the ward and the date, unless 
separate locked receptacles are provided for the use of patients. 

Money and valuables arc separately listed and taken to a special depart- 
ment or given into the custody of the ward sister with the exception of the 
patient’s watch and a little pocket money which he may wish to keep in 
iiis locker for the purchase of newspapers, stamps and so on. 

Injection. In admitting a patient it is very important that the nurse 
should find out whether he has been in contact with any infection. It is a 
good plan to ask whether there are any other ill persons in the house 
from which he has come and, if so, the nature of their illness. It is also 
important to find out if the patient is suffering from a sore throat or head- 
ache, which might indicate the onset of an infectious disease. 

In taking the history — and by this is meant the history of a present 
illness — the following points have to be considered: 

Present complaints^ i.e. of what symptoms the patient is complaining. 

How the illness began^ and whether the patient has been in bed all the 
time; and whether he has been completely in bed, or getting up for 
sanitary purposes. Questions regarding the condition of his appetite^ 
bowels and urine\ the quantity and character of the sleep he usually obtains. 

Having heard and recorded the complaints of the patient, the nurse 
observes which organs are particularly affected, and in taking the sub- 
sequent history she might begin by asking him questions regarding the 
different systems involved. For example, if the patient complains of 
coughing and pain in the chest, she would next make inquiries regarding 
the character of the cough, whether paroxysmal, whether the patient 
coughs more first thing in the morning, or after exertion, or after eating, 
llie existence of any expectoration, character of it, including the colour 
and quantity, whether it is difficult to bring up, and if it has an unpleasant 
taste. She might also inquire whether there is any pain in the chest, 
asking the patient to indicate the position of this. 

Having asked questions on the points about which a patient has com- 
plained, the nurse should then proceed to discover any other symptoms 
and, in order to elicit fairly accurate and comprehensive information, 
she might consider the different systems of the body, taking them each in 
turn and running through them in the following manner. At the same 
time she should avoid putting her questions in such a way as to suggest 
that the patient had any particular .symptom. 

Nervous system. Headache, drowsiness, sleeplessness, any w^anderings of 
the mind or delirium, fits or twitcliings, pain, hyperacsthesia or anaesthesia 
and any other sensory symptoms such as tingling and profuse sweatings. 

Respiratory system. Gough, sputum, breathlessness, and blood-spitting. 

Circulatory system. Palpitation, pain over the heart, swelling of the ankles 
01 other parts of the body, attacks of faintness or fatigue, coldness of 
extremities, pallor or blueness, any sense of fullness in the neck, pulsation 
or throbbing of the blood vessels. 

Alimentary system. Loss of appetite, nausea, dryness of mouth, bad taste 
in the mouth, dirty tongue, any indigestion, flatulence, vomiting, diar- 
rhoea, constipation or abdominal pain. Sometimes dimness of vision, 
black spots before the eyes, headache, skin irritation or jaundice may 
‘iccompany digestive disturbances. 



22 RECEPTION AND ADMISSION OF A PATIENT 

Renal system. Character of urine, regarding quantity, whether scanty 
or copious, the colour and any deposit. Any difficulty in passing urine, 
including any pain on passing it, having to get up in the night to pass 
urine, frequent micturition during the day, the presence of any blood in 
the urine and whether there is any offensive odour. She should also 
inquire whether there is any pain in the loins, or over the bladder, 
whether the ankles swell at night or whether the patient wakens with 
puffiness of the face or under the eyes. Symptoms such as those of nausea 
or headache may frequendy accompany renal disorder. 

Past illnesses. The nature of any other illnesses the patient has had, any 
operations he has undergone, or accidents he has sustained should next 
be ascertained. 

In admitting women patients, the nurse should inquire regarding 
the regularity of menstruation, its character, including the number of 
diapers used, any discomfort experienced, and whether this is sufficient 
to incapacitate the patient; also the presence of any vaginal discharge; 
and she should obtain a brief outline of the history of any pregnancies, 
abortions or miscarriages. 

In admitting a child, all particulars must be obtained from those who 
bring him and, in order to do this effectively, the nurse should make it her 
business to receive the full confidence of the person who may be, and 
probably is, the mother of the child. 

History of birth. It may be possible for the nurse to say, ‘What a lovely 
baby — did he have a normal birth' and having thus gained the mother’s 
heart she will hear the full story of this and can then interpose questions 
which will elicit any history of almormality at the time of birth. 

Breast fed. Whether this was found satisfactory'^, how long it was possible, 
the nature of the weaning; or, if the child had to be artificially fed, the 
type of food used and the results obtained. 

Normal childhood. Whether the child had any infectious diseases; if so, 
at what age, and whether he was nursed in hospital or at home, and any 
complications which occurred. 

Convulsions. Without actually mentioning this terrifying word, the nurse 
in a casual way may say, T suppose the child has never had any fits when 
teething’, and this again will elicit the history as to whether the eruption 
of the teeth was normal or irregular. 

School life. The health when at school, and the regularity of attendance 
— irregularity of attendance usually means defective health, cither mental 
or physical. 

Appetite^ condition of bowels,, and sleepy particularly whether the child 
sleeps all night; particulars of any night fears or bedwetting. 

The hbtory of the present illness will next be elicited on the lines indicated 
in the case of an adult. 

It is usual to ask if the child has been vaccinated and christened. In 
the event of the latter having been omitted, find out the wishes of the 
parents should the child become suddenly very dangerously ill. 

If the child is being admitted for operation, consent for the operation 
should be obtained from the parents. 

The admission bed. The empty beds in a ward are usually made up 
ready for use so that patients can be admitted without delay. In many 



RECEPTION AND ADMISSION OF A PATIENT 23 

hospitals the wards take it in turn to be ready for taking in emergency 
cases. In other hospitals emergency cases arc admitted to any ward at any 
time. It is, therefore, advisable to have a certain number of beds ready 
for the reception of cases in an emergency. The top bedclothes are neatly 
rolled to the side of the bed farthest away from the door, and two. bath 
blankets are placed in position on the bed well covering the bottom sheet 
and the pillow. Toilet requisites, including soap, flannels and towels, 
and personal bed clothing are placed ready on the locker. 

When a patient is expected, and the nature of the case is known, 
certain other articles might be required, such as fracture boards and bed- 
cradles, in case of fracture; bed blocks, in case of bleeding; bedrest and 
oxygen in case of dyspnoea; carbon dioxide and oxygen in case of coal gas 
poisoning and so on. 


OBSERVATIONS OF A PATIENT'S CONDITION 

Nursing observations arc necessary from the moment a patient enters 
a ward until his discharge. The keenness and interest which a probationer 
displays when she first enters the hospital should never be permitted to 
lapse into routine. She should always be on the look-out for something 
new and she will never be disappointed. She must realize that, quite 
apart from the value of her observations in the subsequent treatment of 
the patient, this is one of the ways she has of learning her profession. A 
nurse must teach herself and, when she does this, she will find her con- 
temporaries and seniors ever ready to help her. She must never behave as 
a passenger in her hospital, but always be an energetic member of the 
crew. 

For example, whenever a patient is bathed something new can be 
learnt. It is a mistake to try and be too clever, especially at the beginning, 
or to think 'I can’t make observations because I do not know how to 
classify them’. The best observations are made by people who are content 
to be simple and will therefore record accurately what they see, hear, feel 
and smelL When a patient is admitted it is important to notice his general 
attitude, postures and gait; his mental expression, whether cheerful or 
depressed, whether he appears comfortable or in pain, looks warm or cold 
— he may be trembling or shivering, clean or dirty, fat or thin; the colour 
of his skin should be noted. In this way, before getting him into bed a 
general impression of the type of person one is called upon to deal with 
can be formed. Again, what can be heard — is the patient crying, groan- 
ing or sighing? What is the character of his breathing, is it loud, wheezy, 
soft or shallow, and is he coughing or hawking? Any odour from the 
mouth, body or clothing should be noted. 

Very important observations may be made whilst the patient is being 
put or helped into bed. In most hospitals patients, in whatever condition 
they may be admitted, have their first bath in bed and in no circumstances 
are they permitted to go to the bathroom. This enables the following 
observations to be made : The condition of the hair, whether lank and damp, 
dull or bright, and the presence of nits or lice; the hair should be separated 
in order to ascertain the condition of the scalp. 

The expression of the face, particularly whether drawn as in pain; the 
condition of the eyes, any discharge from them; whether the pupils are 
uneven, normal size; whether the sclera is white, or too bluish white 



24 RECEPTION AND ADMISSION OF A PATIENT 

which indicates anaemia; are they jaundiced or bloodshot? whether the 
eyes are sunken or prominent; is there any squint, ptosis, or other abnor- 
mality of the eyelids, such as oedema, ulcers, deformed eyelashes? does the 
patient wear an artificial eye? 

The nose, whether it moves in breathing, indicating dyspnoea, whether 
pinched and blue, the presence of beads or perspiration on it, whether 
the edges of the nostrils are sore, or covered with crusts, and the presence 
of any herpes round the nose and lips. 

The lips, their colour, whether steady or trembling, whether dry or 
moist, the presence of any sores, cracks or sordes. 

The mouth is carefully inspected when it is cleaned; but at this point 
the nurse might ask the patient to open his mouth, in order to get a 
general impression of the condition of his teeth, and to put out his tongue 
so that she may notice whether it is dry or moist, red or grey, furred, 
cracked or oedematous, whether it is marked by the impression of the 
teeth round its margins, and whether it is steady or trembling. She should 
also notice the odour of the breath. 

The colour of the cheeks should be observed as to whether a malar flush 
is present, whether the capillaries are prominent in this region and, in 
this case, whether they appear red or bluish, whether both sides of the face 
are even in contour and the presence of any facial paralysis. 

The presence of any rash, (See types of skin lesions, p. 498.) 

By this time the patient will have settled down in bed and the next 
thing to notice is the position which he adopts, whether he lies limply on 
his back, taking no apparent interest in his surroundings, or is raising 
himself on his pillows, apparently anxious as to what is to happen next; 
which side he is lying on, whether he objects to facing the light, and 
whether his knees are curled up, which would indicate either that he was 
extremely cold or perhaps in abdominal pain. Notice also where he places 
his arms, particularly if he raises them above his head, which would 
indicate an attempt to assist the movements of the chest in breathing. 
Then notice any pulsation of the veins, or any enlargement of the thyroid 
or lymphatic glands in the neck, and note whether the patient moves his 
head easily or not. 

The skin of the trunk and limbs should be inspected for the presence of 
any rash abrasion, wounds, scars or lumps. The colour should be noted 
and the general condition of the skin, as to whether it is dry and harsh, 
normally soft and flexible, or abnormally wet and sticky. The nurse 
should feel the limbs, and notice whether they are hot, cold, limp, firm, 
whether there is any tremor, whether both sides of the body are equally 
developed, and whether the muscles feel limp and wasted, normally firm, 
or whether they are abnormally spastic and rigid. She should be on the 
look-out all the time for any indication of twitching or convulsion, either 
local or general, and she should investigate every part, particularly the 
abdomen, and the back, each side of the vertebral column, for the pres- 
ence of tender spots. She should note whether there is any odour from the 
patient's body. 

The conditions of hands and feet are deserving of special observation, since 
much can be learnt from them. The development will perhaps suggest 
the type of work, and in some cases be a guide to the temper ament of the 
individual, as to whether he is energetic or lethargic. The age of the 
patient is often indicated by his hands, and by this is meant the physio- 



OBSERVATIONS OF A PATIENT's CONDITION 25 

logical age rather than the actual age in years. The ends of the fingers and 
toes should be observed for the presence of clubbing, and the nails as 
regards colour, character, particularly w^hether cracked and brittle or 
deformed — the state of these is often an indication of the amount of in- 
terest the patient takes in his personal appearance. 

During the procedure of getting the patient into bed, the nurse should 
also notice the condition of the special senses, whether these are perfect. 
She should discover the presence of any hyperaesthesia, and anaesthesia 
of any part of the body. She should observe his mode of speech, and by 
talking to him a little about his condition she may elicit very valuable 
information (see also mode of taking a history, p. 21) such as the con- 
dition of his appetite, his likes and dislikes in regard to food. She should 
find out when he last had his bowels open and any specially trouble- 
some symptoms he may be suffering from, such as coughing, vomiting or 
insomnia. 

By the time the patient is undressed and comfortably settled in bed the 
nurse will have discovered what type of drink he would hke — provided of 
course that he is allowed one — but she should take his temperature, pulse 
and respiration before this is administered. 


EXAMINATION OF A PATIENT 

A nurse should have some knowledge of the routine examination of a 
patient so that she may be able to anticipate the wishes of the doctor whom 
she is assisting. 

The physical examination is carried out as follows: 

By inspection. The light must be good, the room warm and the patient 
comfortable, and not unduly exposed. Inspection provides information 
regarding the general condition of the patient’s body, state of nutrition, 
any deformities, rashes, injuries, irregularities or other marks, the colour 
and character of the skin, the state of the eyes, whether bloodshot or 
jaundiced, presence of pallor or cyanosis, and also any distressing 
symptoms such as dyspnoea, restlessness, twitchings or tic. 

Palpation. By touching and handling different parts of the body, alter- 
ations and variations in development are found. For example, in diseases 
of the lungs, palpation would discover that there was less movement on 
one side of the chest than on the other. Palpation of a tumour would 
provide information regarding its character and size. 

Percussion. By tapping an area of the body over different organs, the note 
obtained will suggest the presence of air, when this is resonant; and of some 
fluid or other cause of solidity when the note obtained is dull. 

Auscultation. This means listening to the sounds of the heart and lungs 
either directly by placing the car against the surface of the body (in this 
case the nurse should provide the doctor with a towel on which to place 
his car), or he may listen by means of a stethoscope. It is very important 
that fidetion rub between clothing should not be permitted to take place 
during auscultation. 

Preparation of the patient for any definite form of examination. 
The patient should be told of the nature of the examination unless he is too 
ill, or for some reason incapable of taking any interest in the matter: for 
t'xample, a patient who is in an exceedingly toxic state will be quite 



26 RECEPTION AND ADMISSION OF A PATIENT 

oblivious to anything that may be happening. The following points should 
be taken into consideration: 

The light should be goody whether it be artificial or natural. The patient 
should be placed in such a position that shadow does not fall on the part 
under examination. 

Absolute quiet is essential — the patient should not talk and the nurses 
should move as quietly as possible. The bedclothes should be handled 
quietly and gently, as even the rustling of these may make it difficult 
for the doctor to detect the sound he is listening for, or the note he is trying 
to elicit in percussion. 

The bed and personal clothing should be conveniently arranged so that different 
parts of the body can be exposed with comparative case, without undue 
movement and unnecessary exposure of the patient s body, as the examin- 
ation progresses. For examination of the chest the bedclothes might be 
folded down to the level of the patient^s waist. The personal clothing could 
either be removed, or the jacket or gown merely held out of the way so 
that the clothing does not come in contact with the doctor's hands, or 
with his stethoscope, as the examination proceeds. 

Only one part of the patient's body — that which is under examination 
— should be exposed at a time, covering the parts finished with from time 
to time. Whenever possible it is a good plan to have the patient's shoulders 
draped with a blanket, shawl or jacket which can be easily drawn round 
him, and as easily removed when required. 

For examination of the chest the patient may be lying in the semire- 
cumbent position or sitting. If he is sitting, support should be supplied 
for the lower part of the back so that his lumbar region docs not ache. 
As separate sides of the chest are examined the nurse should turn the 
patient’s head from side to side so that he does not breathe directly into 
the doctor's face. 

When the back of the chest is to be examined, the personal clothing 
should either be removed or drawn well up to the root of the neck, and 
well forward on each side, so that the area of the axillae is clearly visible. 
The patient may sit up leaning forward, or lie forward on one side in a 
semi-prone position. When the former posture is used, draw the pillows 
dowm to the small of the back as the patient sits, to give support here; 
and support the patient from the front by putting one arm across his chest, 
unless the doctor prefers that he should lean forward — in this case see that 
the patient's arms are resting on his knees in front of him, and not held 
stiffly at his sides. 

Examination of the abdomen. It is important that the bladder be 
empty, otherwise the patient is inconvenienced by anxiety about this. The 
patient should lie on his back quite straight and flat with his arms down 
by the sides of his body. The doctor may require his knees to be either 
straight or slightly flexed; in the latter case a soft knee pillow may be 
provided. The shoulders and chest should be protected by a small jacket, 
or by a blanket folded round, shawl fashion. The bedclothes should be 
folded down to below the pubes as the patient lies ready. The lower 
part of the trunk may be covered by a blanket, or in warm weather 
merely by a sheet; either can easily be moved about during the examin*^ 
ation. It is a good plan to tuck one of the blankets, which has been folded 
down, under the patient's buttocks; this prevents the clothes slipping, 



EXAMINATION OF A PATIENT 27 

and gives a sense of confidence that exposure will be avoided, for which 
the patient will be exceedingly grateful. 

When the pubic region is included in the examination it is usual to place 
a towel over the folded bedclothes, as the nurse will find it easier to 
manipulate this small article during the doctor’s movements. 

If a woman patient is undergoing abdominal examination, and students 
are present at the bedside, a towel might be provided with which to shield 
her face, in order to avoid embarrassment. 

Examination of the legs and feet. — For examination of this portion 
of the body, the bedclothes should be untucked at the sides and bottom 
of the bed, and turned up to above the knees, leaving one sheet or blanket 
over the legs. Only the leg to be examined ought to be exposed. If both are 
to be examined the sheet can be turned back on to the other bedclothes, 
or pleated up in folds to lie between the legs, so that it can be in readiness 
to cover one leg when one is finished with. 


EXAMINATION OF THE DIFFERENT CAVITIES OF 

THE BODY 

Examination of the mouth and throat (see fig. i6, p. 145). The 
nurse should supply a good light, a warm tongue spatula, a receiver in 
which to place it when soiled, a towel to put under the patient’s chin, and 
a mouth-wash to be used afterwards. Swabs and culture glasses should be 
at hand in case these are needed. 

If a nurse is examining the throaty in order to be able to report upon its 
condition, she should ask the patient to open his mouth, and observe the 
condition of his tongue , w^hether it is clean or furred; the presence of any 
cracks or fissures, and whether the patient moves it easily or not. The 
teeth and gums should be observed regarding their colour, whether they are 
healthy or pale and spongy, and the presence of any sordes on the teeth. 
The condition of the lips should be inspected to see whether these are cracked 
or fissured; whether there are any little ulcers or sores on the inside of the 
lips; the presence of herpes, and the colour of the lips should also be noted. 

In order to inspect the throaty the nurse should ask the patient to put his 
tongue out and say ‘ah’. This will permit examination of the upper part 
of the pharynx. She should then take a spatula, place it gently on the 
tongue, as the tongue lies in the mouth, not protruded. She should place 
the spatula about halfway along the tongue and press gently, and again 
ask the patient to say ‘ah’, when the soft palate and uvaila; and posterior 
phar)'ngeal wall and tonsil area can be seen. She will notice whether 
these tissues are pale, injected or congested, whether there is any exudate 
or any membrane, whether any deposit is present in the follicles of the 
tonsils, or whether the whole area is covered with an exudate. 

As the mouth and throat are examined, the odour of the breath should 
be noted. 

Examination of the rectum (see fig. 17, p. 145). For a rectal 
examination performed in bed, a lubricant, antiseptic lotion, gloves, 
swabs and towels are all that will be required. Should a specimen be taken, 
cotton wool applicators and sterile test tubes will be needed in addition. 
For a more extensive rectal examination a protoscope and light will b^ 
needed (see also sigmoidoscopy, p. 2^5). 



28 RECEPTION AND ADMISSION OF A PATIENT 

The patient should be prepared by having the bladder and rectum empty. 
The external parts should be quite clean and protected by towels. The 
patient may lie on his back, in a semi-recumbent position, or in the left 
lateral or the Sims’s semi-prone position for simple examination. For more 
extensive examination in which a proctoscope is used the surgeon may 
prefer to have the patient kneeling on the bed, leaning forward resting 
on his head with his arms hanging by his side, which is a modification of 
the knee-chest position and one used solely for this form of examination. 

Examination of the vagina. This examination is usually performed 
with the patient in bed, except in the theatre where the lithotomy position 
would be used. When in bed, the examination will be performed with the 
patient in the left lateral position, in the Sims’s semi-prone, or the dorsal 
recumbent position. In some instances two of these positions are used. The 
patient lying in the left lateral position has the vagina examined and is 
then turned on to her back for bimanual examination in which the anterior 
abdominal wall is palpated with the examiner’s free hand at the same 
time. In preparing patients for these various positions, the bedclothes 
should be folded to below the level of the knees, leaving only one sheet 
or blanket covering the patient. The bedgown must be well rolled up, and 
if the patient feels cold, or the weather is cold, long warm stockings should 
be worn. 

In the preparation of the patient the bladder and rectum should be empty, 
and the external genitals and perineum recently washed. 

The articles required (sec fig. 172, p. 521) for this examination include 
gloves, antiseptic lotion, a lubricant, swabs and towels, and some form of 
vaginal speculum, either Fergusson’s, Sims’s or Cusco’s. It is important 
that the nurse should see that these are sterile and are delivered warm, 
by having them ready in a basin of warm water. Swabs and sterile test 
tubes and culture glasses may be needed. 

In a few instances and particularly when the examination is performed 
in the lithotomy position, tenaculum and uterine forceps, Playfair’s probe 
and a uterine sound may be required in addition. 

For examination of the ear, nose and throat sec p. 721, and for 
examination of the eye, p. 736. 


DISCHARGE AND TRANSFER OF PATIENTS 

The discharge of a patient, either to his home or to some other hospital 
or to an institution, is a very important undertaking. He has been the 
guest, in the case of a voluntary hospital, of the subscribers and he has 
been treated, cared for and attended to by a number of the members of 
the hospital staff, some of whom give their services while others arc paid 
for theirs. Everything therefore should be done to make his departure easy 
and as free from anxiety as possible, and he should also be given an oppor- 
tunity to express his opinion as to whether he has been conrfortable during 
his time in hospital and whether there is anything he would like to say 
regarding this. To secure that the answer to such inquiry may be made 
as freely as possible, it is usual in some hospitals for a member of the 
secretarial staff or one of the almoners or, in their absence, the officer who 
is in charge of the hospital or one of his or her subordinates, to visit the 
patient for this special purpose. 



DISCHARGE AND TRANSFER OF PATIENTS 29 

A day or two before the date of discharge the relatives or friends are 
informed that they may come for the patient at a given time on a stated 
day and, if they have taken his clothes home, they are asked to bring them 
when they come. 

The ward sister sees that the patient is ready to go home, that he is 
recently bathed, that his head is clean and that he has safely in his own 
custody, if he is capable of this, any articles of his own which he has been 
using and, at the last minute, any valuables which have been kept safely 
locked up for him. It is her duty to see that the patient clearly understands 
the nature of any treatment which is to be carried out at home — she will 
also supply the relatives with details about this — and that he knows 
whether he is to come up to the hospital to be seen again and, if so, that 
he is quite clear about the date and time of this visit. 

A discharge slip is usually made out the evening before, after the patient 
has been medically examined. This is sent to the office of the medical 
officer who is in charge of the admission and discharge of patients, for his 
signature. It contains information regarding the name of the patient, 
the ward, the member of the honorary medical staff under whom he has 
been treated, and the date of the patient’s admission and discharge. 

When the friends arrive with the clothes the patient is dressed, the ward 
sister sees that they are given all the patient’s belongings and in most cases 
either she, or her head nurse, accompanies the patient to the door of the 
hospital, conducting him downstairs in a lift, assisting him as necessary, 
providing a wheel chair if required and taking pains to see that he does not 
carry anything himself — as the patient, especially if a man, will object 
if a nurse carries his suitcase for example — but he is still a patient and this 
must be tactfully explained and he must submit. She will then hand him 
over to the head porter at the door, say good-bye to the patient, and 
arrange for the porter to obtain a conveyance for the patient if he wishes 
to have one. 

Transfer to another hospital or institution. Should a patient have 
to be transferred to another hospital, it is usual to inform the relatives of 
this first; if the transfer has to be made quickly, it must proceed before 
they may have received the information, but the nurse, whilst making 
arrangements for it, must try to get into touch with the relatives. If, 
however, they have not arrived by the time the patient departs, she 
must see the driver of the ambulance or other person who comes to take 
the patient away, and obtain the address of the place to which the 
patient is going, in order to give or send this to the relatives at the earliest 
opportunity. 

As a rule all the patient’s belongings will be sent with him — if not, they 
are given to the relatives when they call and a receipt is obtained. 

Transfer to another ward in the same hospital. The management 
of hospitals varies considerably in the arrangement of this matter. The 
majority probably require the patient to be discharged and readmitted, 
should he be transferred from a medical to a surgical ward for example. 
But should he be transferred from one medical or one surgical unit to 
another, this is not usually necessary. In the former case, the discharge 
slip will be made out and sent to the medical officer as before, and the 
sister will go to the admitting office and have the patient readmitted to 
the ward to which he is going. 



30 RECEPTION AND ADMISSION OF A PATIENT 

She will then see the sister of this ward, find out when it would be most 
convenient for her to receive the patient and send him to her, giving at 
the same time any information she can about his condition and treatment, 
particularly witli regard to the diet the patient is having. 

Case sheet. Immediately on the discharge of a patient the ward sister 
examines the bed card, sees that it is complete, removes any unused sheets 
and sends it to the department where records are kept; unless the patient 
has been transferred, in which case she sees that the bed card accompanies 
the patient to his new ward. 

Treatment of the bed and other appurtenances, after discharge 
of a patient. Immediately after the discharge of a patient the ward sister 
arranges that the nurse who has been in charge of the case, or in her 
absence another nurse, strips the bed, sends all linen to the laundry, 
brushes and, if a balcony is available, airs the mattress, pillows and bed- 
ding, washes all mackintoshes, and all the utensils used by the patient, 
turns the locker out, has it washed and scrubbed if necessary and when dr)^ 
puts clean paper in, and washes the bedside chair. 

The bedstead is then carbolized, first placing a sheet on the floor to pro- 
tect it from drippings; the bed is dried and polished and the bed made up 
clean. 

Fresh charts and bed cards are replaced on the bedboard ready for the use 
of the next patient; insertion of the visiting cards also will ensure they are 
ready to be given to the relatives on admission of the patient who is next 
to occupy this bed. 

The discharge of a patient with an infectious disease, or one who 
has been suffering from some infective condition, such as septicaemia or 
erysipelas for example, is rather more complicated. After any infection, 
however slight, the mattress, pillows, bedding and linen, both the bed 
linen and patient's personal linen, should all be steam disinfected, and 
ail the utensils which have been used for the patient should be sterilized 
by boiling or by chemical means. The soap and washcloths should be 
burnt. The area of the floor around the bed, and between it and the 
adjacent beds, and wall space behind this area, should be well washetl 
with soap and water. If the patient has been occupying a separate room 
or small isolation ward, the ward might be closed for formalin fumigation. 
(For terminal disinfection of patient sec p. 465.) 



Chapter 2 

Temperature, Pulse and Respiration 

Temperaturt: The mriations of temperaturt in health and disease — Methods of 
taking the body temperature — Notes on the febrile state — The stages of a rigor. Pulse: 
The variations of the pulse in health and disease — Abnormal pulses — Blood pressure 
— Respiration: Variations of respiration in health and disease — Abnormal respira- 
tion — Dyspnoea and cyanosis 

T he normal body temperature is ^8,4"" F., having a diurnal range 
from 97.4^ to 99*^. The temperature is taken by means of a clinical 
thermometer, which registers from 95° to 110° on the Fahrenheit 
scale. It is a self-registering thermometer having a slight constriction in the 
glass tube immediately above the bulb of mercury which prevents the 
mercury, which has risen up the glass tube in response to the heat to 
which it has been subjected, from falling again until it is shaken down. 

In health very little variation of temperature occurs. The degree 
recorded depends on the part of the body in which the temperature is 
taken. A rectal temperature gives the highest reading, probably two 
degrees higher than the skin temperature and one degree higher than a 
temperature taken in the mouth. In conditions of starvation and after 
exposure to cold and during sleep the temperature is a little lower. It 
may be slightly increased by muscular activity, by mental excitement or 
any other form of nervous tension and also by taking a hot bath or sitting 
closely over a fire or by exposure to an abnormally high, humid atmo- 
sphere; but these variations are very slight and no more than temporary. 
The body temperature is higher in the evening than in the morning. 

VariationB in disease. The temperature is decreased in all conditions 
which produce dehydration, as in vomiting and diarrhoea, severe 
haemon hage, marked toxaemia and in conditions of shock and collapse. 
It is also depressed in certain conditions of auto-intoxication as in 
jaundice. The temperature is increased in all febrile conditions, of which 
there are many causes in medicine and surgery, including infective con- 
ditions, metabolic disorders, and derangements of the heat-regulating 
centre such as occurs in certain nervous conditions. 

It is very important for a nurse to realize that a condition of fever, 
pyrexia or temperature — all these terms being used synonymously to indi- 
cate a rise in temperature — is protective in function because the increased 
temperature is antagonistic to the growth of the organisms causing the 
disease. It is also thought by some that the increased heat assists in the 
formation of immunizing bodies. 

Degrees of temperature (Fahrenheit scale). 

Hyperpyrexia^ over 105°. 

Pyrexia: High — 103® to 105°. 

M<^crate loi® to 103®. 

Low — 99® to 1 01®. 


31 



2 TEMPERATURE, PULSE AND RESPIRATION 

Normal 98*4° (ranging from 97-4® to 99°). 

Subnormal — 95° to 97°. 

Collapse below 95°. 

Types of Fever (temperature or pyrexia). 


Constant. Remittent. Intermittent 



Fig. I. — ^Types of Pyrexia. 

Constaniy when the fever, remaining high, varies not more than two 
degrees between night and morning. 

Remittent y a fever characterized by variations of more than two degrees 
between night and morning, but which does not reach normal during 
the 24 hours. 

Intermittent, This is also described as hecticy or swingingy because the 
range of temperature varies from normal or subnormal to high fever at 
intervals varying from 24 hours to two or three days, but whatever their 
duration they occur with a fair amount of regularity. 

Irregular. A fever not corresponding to any of the above three groups, 
but manifesting characteristics of some or all of them at one time or 
another. 

Inverse. In this the highest range of temperature is recorded in the 
morning hours, and the lowest in the evening, which is contrary to that 
found in the normal. 

Apyretic. Sometimes a fever, typhoid fever for example, will run its 
course without any increase in temperature. This is described as an 
apyretic type. 


TAKING THE TEMPERATURE 

The articles required are : a clinical thermometer standing in a jar with 
cotton wool at the bottom in order to protect the end of the bulb, the 
jar being three parts filled with some disinfectant solution, such as 1-20 
carbolic, 1-1,000 perchloride of mercury. 

Ajar containing some either moist or dry wool swabs with which to wipe 
the thermometer after use, a receiver in which to place the used swabs. 
It has been found that wiping the thermometer with wool adequately 
cleanses it because the surface is shiny and smooth so that germs do not 
readily adhere to it. If there is a sirik handy, the thermometer is held 


TAKING THE TEMPERATURE 33 

under running cold water for a few seconds after taking it from the 
patient before wiping it. 

The temperature may be taken most conveniently in the mouth, rectum 
or on the skin of the axilla, groin or popliteal space. The thermometer 
should never come in contact with a diseased part. 

The mouth. The temperature may be taken in the mouth, except in 
the case of infants, unconscious, delirious or insane patients, or where 
keeping the mouth closed would inconvenience the patient as in conditions 
characterized by cough, dyspnoea, or obstructed nasal breathing. 

In taking the temperature in the mouth, the patient is asked to open 
his mouth, then the thermometer is placed under the tongue, and he is 
told to close the lips but not the teeth on it. The nurse should then con- 
sider whether it is necessary for her to hold the thermometer or not. 

The rectum. A special thermometer should be kept for this, and it 
should have a short blunt bulb. In many hospitals quite distinctive ther- 
mometers are used, filled with alcohol instead of mercury, and having a 
coloured bulb. 

Before insertion the thermometer should be lubricated with vaseline 
for about two inches of its length, care being taken not to lubricate it 
too heavily lest the lubricant by forming a coating should make an 
accurate reading difficult. In the case of infants the patient should either 
be held face downwards on the lap for the insertion of the thermometer; 
or, if lying in the cot, the legs may be held up with the left hand and the 
thermometer passed into the rectum with the right. In older children 
and adults the thermometer can be inserted while the patient is in almost 
any position. In all cases it is very important that the patient should be 
held steady while the thermometer is in the rectum, and it should be 
inserted for quite two inches. 

Skin reading. Whether the temperature is taken in the axilla, groin or 
popliteal space, it is important to see that the skin surfaces are dry, and that 
the thermometer bulb is closely in contact with two skin surfaces in order 
to exclude air, since upon this the accurate recording of the temperature 
largely depends. 

After taking the temperature read the thermometer carefully, make a 
note of it, then shake the mercury down below F., wipe or wash the 
thermometer and replace it in the disinfectant. 

To shake a thermometer down take hold of it between the thumb and two 
fingers of one hand, grasping the lower third of the thermometer just above 
the bulb, hold it away from the body, supinate and extend the forearm 
and extend wrist, and then sharply pronate and flex the wrist. 

I'he titne required to obtain an accurate reading varies according to the area 
where the temperature is taken, and with the type of thenuometer used — 
some thermometers are supi>osed to record a temperature in half a 
minute, one minute, two minutes and so on, but to obtain an absolutely 
accurate reading five minutes should be allowed. 

I'he mercury will rise most rapidly in the rectum because in the interior 
of the body the surfaces are very close together, and air is excluded. The 
next quickest record will be obtained in the mouth, and it will take longest 
when the skin surface is used. It has been found by experience that a 
thermometer marked to record a temperature in half a minute will usu2illy 



34 TEMPERATURE, PULSE AND RESPIRATION 

do SO if the patient is suffering from a fairly high de>grce of fever; but, in 
cases where there is a low degree of pyrexia, an accurate reading will 
usually not be obtained under five minutes (sec p. 33). 

If the nurse is at all in doubt as to the reading she has obtained and 
thinks it does not conform to what she knows the patient’s condition might 
ead her to expect, she should take the temperature a second time. If she 
doubts the accuracy of the thermometer, she should use a second one and 
test the first by placing it in a little water not over 100° F. In a few in- 
stances she may have to be on the look-out for the recording of a false 
temperature either accidentally, or intentionally assisted by the patient. It 
may be that the patient has recently had a hot drink, or has been smoking, 
which might alter the temperature of the mouth locally for say half an 
hour. If a hot water bottle had been near the axilla or other skin surface 
used, the same thing might happen there. A skin temperature should not 
be taken within half an hour of having a bath. 

Specially made thermometers are necessary in certain cases. One gradu- 
ated to register a temperature as low as 85° F. may be needed for accur- 
ately recording the temperature of premature babies. On rare occasions a 
patient acutely ill may run a temperature above 1 10° F., in which case a 
special tliermometer will have to be made. 

NOTES ON THE FEBRILE STATE 

The course of a specific disease, characterized by a rise in tempera- 
ture, is divided into different stages: 

(1) Following the incubation period is the stage of onset or invasion 

during which the first symptoms appear. 

(2) The full development of the disease is described as the fastigium^ 

stage of advance, or height of the fever, 

(3) This is followed by decline of the symptoms, including the tempera- 

ture, as the disease passes into the last stage — that of convalescence, 
when the normal is gradually re-estaUished. 

Mode of onset and decline of fever. A disease characterized by a rise 
in temperature may have a rapid or a gradual onset. In the former a very 
high temperature is reached in a few hours, freciuently being ushered in by 
an attack of shivering which may be severe enough to be a rigor; in 
children convulsions more often occur. In the case of a gradual onset the 
temperature rises a little each day until, at the end of several days or a 
week, it has reached its maximum degree. 

Similarly the fever may decline suddenly when the temperature falls in a 
few hours, within 24 at most; this is termination by crisis, provided that 
there is a corresponding, though perhaps not such a complete, drop in 
the pulse and respiration rate. 

It sometimes happens that during the course of a serious febrile disease 
such as pneumonia the temperature falls but there is no accompanying 
decrease in pulse and respiration rate and the temperature rises again; 
this is described as false crisis. 

Lysis. This is the term used to describe a more gradual decline of fever 
when it takes from 2 to 10 days or longer to return to normal. A short lysis 
such as is seen in scarlet fever occupies about 3 days; a long lysis, for 
example that usually seen in enteric fever, may occupy from 7 to todays 
(see accompanying charts). 



NOTES ON THE FEBRILE STATE 


35 



Fig. 2. — Lobar Pneumonia. 

Example of abrupt onset and 
decline by crisis. 


OAX 

X 

-A, 



4i 

y 

-.J 

too 


JSUJL 

i 



Ml. 

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Fio. 3 . — Scarlet Fever. 

Example of decline of 
fever by lysis. 



Fio. 4.— Enteric Fever. 
Example of gradual onset of fever. 


Symptoms which accompany the febrile state vary with the nature 
of the disease from which the patient is suffering. They can most con- 
veniently be considered according to the changes produced in the various 
systems; 

Respiratory system. Increased rate of breathing. 

Circulatory „ Increased pulse rate, cold extremities. 

Alimentary „ Dry mouth, dirty tongue, loss of appetite, indi- 

gestion, nausea and vomiting, constipation or 
diarrhoea. 

Excretory „ Diminished urinary output, high-coloured urine 

depositing urates on cooling, possibly albuminuria. 




^5 temperature, pulse and respiration 

Muscular system Malaise and fatigue and general aches and pains 
with weariness. 

Mervous „ Headache, restlessness, maybe irritability and 
insomnia. The skin may be hot and dry or hot and 
perspiring. Shivering or rigors, fits, twitchings, 
convulsions or delirium may occur. 

Nursing a febrile case. Probably the most important point to be con- 
sidered in nursing a patient who has a high temperature is to endeavour 
to relieve this as much as possible, or at least to provide conditions which 
will not aggravate it. 

It is a mistake often made to pile extra bedclothes on to the bed of a 
patient so afflicted; instead, bedclothes should be removed, leaving the 
patient covered with a light blanket and in some cases only a sheet. Per- 
sonal bed clothing should be as light as possible, non-irritating, and should 
not fit too well. Bcdsocks and hot water Ixittles might be removed. 

The room should be well ventilated, as warm as is considered necessary 
according to the condition of the patient, but the windows may be freely 
opened provided the patient is protected from draughts. 

Cooling drinks, given frequently, will help; in addition the fluid will 
moisten the tissues, and so make the mouth cleaner and the tongue moist 
instead of dry, relieve the thirst and help rid the body of toxaemia by 
providing more fluid to be eliminated by means of the different excretojy 
channels as it dilutes the waste products of metabolism and renders the 
work of these organs more efficient. 

Sponging the hands helps the patient to feel cooler. Apart from the routine 
washing an occasional sponging of the skin of the whole body wifl cool 
and comfort a patient and may induce sleep which, by providing <is it docs 
the best form of rest, will aid recovery by increasing the patient’s resistance 
to disease. 

In most febrile cases the diet should be light but plenty of fluids should 
be given. The bowels should be dept daily acting if possible without the aid 
of aperient drugs; orange and prune juice being used instead and, if 
necessary, liquid paraffin. If aperients are ordered it is important to see 
that they do not purge the patient. 

Reduction of a temperature. As stated elsewhere a rise in tempera- 
ture is one of the protective mechanisms of the body, and drugs are there- 
fore not, as a general rule, used in order to reduce it. It is generally con- 
sidered inadvisable to permit a patient to sustain a temperature of over 
105° F., or in some instances over 103°, for long at time, as this leads to 
great prostration often accompanied by delirium, which lowers the 
resistance of the patient and retards his recovery. It is therefore customary 
to order these cases to be sponged with tepid or cold water or to have some 
other general cold or cool application made to the body (sec p. 122) 
in order to relieve, for a time, the degree of fever present. 

A special note is made of the time this treatment was used and of the 
effect obtained and, in order to note its general effect, the result is charted 
as shown on the accompanying illustration on p. 123. 



RIGOR 


37 


RIGOR 

A rigor is a severe attack of shivering which may occur at the onset of 
disease characterized by a rise in temperature, such as pnevimonia. It may 
also arise during the course of infective diseases and conditions. A rigor is 
marked by three stages which arc fairly distinct one from another: 



Fio. 5. — Example of Rigors occurring in Benign Tertian Malaria. 

The first or cold stage in which the patient shivers uncontrollably. The 
skin is cold, the face pinched and blue and the pulse rapid and small. 
The temperature is rising rapidly and may reach 104° F. whilst the patient 
still feels cold. 

The second or hot stage follows immediately. The patient is now uncom- 
fortably hot, his skin hot and dry, and he suffers thirst and headache and 
tosses about in bed in an agony of restlessness. The pulse becomes fuU. 
The temperature may continue to rise. 

The third or stage of sweating sets in. The skin acts, the patient sweats pro- 
fusely, the temperature falls, the pulse improves and the fonner acute 
discomfort abates, though the patient is now conscious of his dripping 
skin and if not well cared for will get very cold and may collapse. 

Nursing. A patient should not be left alone during a rigor. The 
different stages require appropriate treatment. During the shivering attack 






mm 

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mam 

mm 


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muffin 

R 

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MMMil 


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imiffw 


Fio. 6. — ^Method of Recordino Temperature during Rioor. 





^8 TEMPERATURE, PULSE AND RESPIRATION 

the patient must be given hot drinks, have hot blankets put around him 
and his bed maintained at as high a temperature as possible; but as soon 
as he begins to feel hot this treatment must cease. His temperature is care- 
fully recorded every lo or 15 minutes throughout the rigor, and should it 
rise to 105® F. or over it is usual to cool-sponge him. At this stage he is 
given cool drinks, cool compresses arc applied to his forehead or an ice- 
bag to his head to relieve his sensation of head congestion and the pain 
he is suffering. 

The first signs of sweating are carefully watched for, as this must not be 
retarded by cold applications; they should then cease, the temperature 
being recorded as before so that the rate at which it is falling is constantly 
observ^ed. The sweat must be wiped by the nurse at his bedside from the 
patient’s face, neck and chest to prevent discomfort. At intervals as neces- 
sary she will rub him down and change his clothing for dry clothing, 
and watch his colour and pulse most particularly as now, at the end of the 
suffering entailed by a rigor, he may be exhausted. A stimulant may have 
been ordered which can now be given and if made very comfortable the 
patient may sleep and thus obtain rest. He should be watched constantly 
and his pulse rate and its character noted at least every 15 minutes for 
some hours. 


THE PULSE 

The pulse is the heartbeat — conveniently felt at the wrist. Each pulse 
represents a cardiac cycle. A cardiac cycle includes a period of systole or 
contraction, diastole or rest. The pulse may be felt at any point where an 
artery' passes superficially and lies over a bone. It is most conveniently felt 
at the radial artery below the root of the thumb. 

The normal pulse rate varies with age and sex, and with the position 
of the patient, being more rapid when standing than when sitting and 
slowest when lying fully relaxed. It is increased in conditions of excitement, 
including anger, fear and anxiety. It is decreased during sleep, and to a less 
extent during rest and relaxation. 

Pulse rate. In a newborn infant — 140 beats per minute. 

At 12 months — 120. 

From 2 to 5 — about 100. 

From 5 to 10 — about 90. 

Adult^ from 70 to 80, being five beats quicker in a woman 
than in a man. 

In old age, pulse usually becomes slower. 

In extreme old age, it may quicken again. 

As a rule the ratio of the pulse to the respiration rate is that there are 
four pulse beats to every respiration. Its ratio compared with temperature 
suggests that, other things being equal, the pulse will rise 10 beats with 
every degree of fever over loo*’ F. 

A normal pulse should show the following characteristics. Its rate should 
correspond with the age of the person. The rhythm should be regular, the 
volume moderate, and it should not be too easily compressed. I’he blood 
vessel should be soft and pliant under the examining finger but not wiry or 
tortuous. 



THE PULSE 

In taking a pulse the patient’s hand and 
arm should be supported, and the muscles on 
the anterior aspect relaxed; this may be ob- 
tained by flexing elbow and wrist as the limb 
lies on the bed. If there is no indication to 
the contrary the arm might be laid across the 
patient’s chest or abdomen. If this is not pos- 
sible, then it should be supported on a pillow 
as in fig. 7. 

The nurse gently places three fingers of one 
hand on the anterior surface of the forearm, 
just above the wrist, and feels the pulsation 
of the radial artery here. She notes the rate, 
rhythm, volume, tension and degree of com- 
pressibility and the condition of the artery. 

When she is familiar with the general char- 
acter of the pulse she is feeling, she begins to count, and counts for a minute, 
taking particular care that she begins to count when the finger of the 
second hand of her watch is on a definite figure, usually at the | or full 
minute mark. If in any doubt as to the accuracy of her findings she begins 
and counts the number of beats again until she is satisfied. 

Should the wrists not be available the pulse may be taken at some otlier 
part — the temporal artery being a convenient place. 

It is a wise plan, on the admission of every new patient, to take the 
pulse at both wrists simultaneously, as in some conditions — such as for 
example an aneurysm of the blood vessels of one side — the pulse would 
be found to be slightly delayed on the affected side and this might be 
the first means of detecting the condition. 


39 



Fio. 

Support the hand and flex 
the wrist when taking the 
pulse. 


ABNORMAL PULSES 

The pulse may vary in its different characteristics: 

Rate. A rapid pulse may be anything up to 140 — above that it is 
difficult to count. A term used to describe any rate above 100 is tachycardia^ 
and this state may be continuous or paroxysmal. It may be functional in 
character or due to organic disease. A slow pulse is described as brady- 
cardia. It may be due to the fact that the cardiac contractions are not strong 
enough to reach the radial artery. 

The cardiac impulse starts in the sino-auricular node near where the in- 
ferior vena cava communicates with the auricle. From here it is trans- 
mitted through the auricle to the bundle of His^ which is a highly specialized 
neuro-muscular bundle which picks up the auricular impulses and as it 
were stablizes them, acting as a pacemaker (which it is frequently called), 
and passing them on to the ventricle. The ventricle contracts in order to 
force blood into the arteries, and this contraction transmitted along these 
vessels becomes the pulse wave. A second wave , due to closure of the aortic 
valve, is described as a dicrotic wave. In conditions of heartblock^ which con^^ 
dition may be partial or complete, impulses do not reach the ventricle. 
If partial, a ventricular beat, and consequently a pulse beat, may be 
missed at regular or irregular intervals. In complete heartblock, when no 
impulses pass, the ventricle contracts independently of any control from 



40 TEMPERATURE, PULSE AND RESPIRATION 

the auricle, and this results in a very slow pulse, usually bdow 40, and is 
always a serious condition. 

Variations in rhythm. By rhythm is meant that beats occur at regular 
intervals and the distance between them is equally regular, and any 
interference with this results in a state of arrhythmia. 

A pulse is described as intermittent^ when beats arc missed — for example, 
every third or fifth beat may be missed, or the pulse may be irregularly 
intermittent. In taking such a pulse the nurse should count the cardiac 
impulses by placing her fingers over the apex beat of the heart which she 
will find a little to die left of the nipple line and just below it, or she might 
use a stethoscope for this purpose, in order to satisfy herself and enable 
her to make an accurate report of cardiac beat and pulse beat. 

A pulse is irregular when the pauses between the beats arc of varying 
lengths. Beats are not missed, they simply run together at one time and 
are widely separated at another. This condition is seen in cases of extra 
jystole^ when some of the cardiac contractions occur prematurely, that is, 
before they are normally due in the cardiac cycle. This is caused by irrita- 
bility of the muscle. The premature beat occurring before the heart is 
quite ready for it is weak in character and unable to transmit the impulse 
to the arteries. 

Auricular fibrillation is a condition in which the auricles, being very irri- 
table, are quivering rather than contracting. The bundle of His deals with 
this as best it can, but the result is a rapid and irregular pulse. 

In sinus arrhythmia the pulse is rapid during inspiration and slower dur- 
ing expiration. This is comparatively unimportant and occurs most com- 
monly in children and, if the child is asked to hold his breath, the 
irregularity will disappear. 

Strength. A pulse contraction should be strong enough not to be too 
easily compressed. This is intimately bound up with the condition of 
volume^ that is, the amount of blood in the artery. The pulse is described 
as full, or large, or small, according to its volume. The tension also deter- 
mines to some extent the degree of compressibility. A high tension pulse 
is difficult, and a low tension is easy, to compress. Other abnormalities 
involving these characters include a thready pulsCy which is one which is 
rapid and weak and easily compressible; a running pulse when in addition 
the tension is markedly low; and a wiry pulse which is the type met with 
when the arteries are hard, and yet at the same time the pulse is weak and 
rapid and thready. 

Pulsus alternanSy which occurs when the contraction of the ventricle varies 
and results in alternately weak and strong pulse beats, is usually serious. 

Another point that the nurse must be very careful to observe when 
taking the pulse, is the condition of the artery as it lies under her examin- 
ing finger. Normally it would be soft and pliant. She should note whether 
it is flabby and lacking in tone, or wiry, hard and tortuous. 

Dicrotic pulse. In conditions where prostration has been very marked, 
or grave toxaemia has been present for a long time, the muscles become 
toneless; when this happens to the muscles of the blood vessels, the flabbi- 
ness permits the dicrotic wave, spoken of on p. 39 to be felt. This is ex- 
perienced by the nurse as if she were feeling a pulse beat followed by an 
echo of a beat, She is really feeling a true pulse wave and also the dicrotic 



ABNORMAL PULSES 4 1 

wave, present normally, but not normally perceptible. She should therefore 
take the cardiac contraction rate at the apex beat and compare the two. 

Corrigan’s pulse. This is named after the doctor who first described it. 

It is also described as a collapsing pulse ^ and walerhammer pulse. It is present 
in cases of aortic incompetence, where the blood, having been forced into 
the artery by the ventricular contraction, regurgitates back into the ven- 
tricle owing to the non-closure of the aortic valve. In taking this pulse the 
wave is felt to rise and then immediately recede. It can be more definitely 
experienced by raising the patient’s arm. 


BLOOD PRESSURE 

Nurses are sometimes required to keep records of a patient’s blood pres- 
sure. This can only be done by means of a sphygmomanometer. 

The normal blood pressure is estimated as being lOO plus the age in 
years. Systolic pressure is greater than pressure during diastole. In a man 
of 20 the systolic pressure is estimated as being 120, the diastolic pressure 
will be fairly constant a I about 70. 

The pulse of a person with high blood pressure, hyperpiesis or hyper- 
tension, is described as hard, full in volume and difficult to compress. That 
in a person with low blood pressure, or hypopiesis, is low in volume, soft 
in character and easily compressed by the examining finger. 

Persistent hypertension leads to cardiac dilation and results in the pulse 
which is described as wiry, which means that it is hard but not of large 
volume — a similar condition in a person with normal blood pressure 
would give rise to a weak, thready pulse, but in the present instance it is 
wiiy, not thready. 

To take a reading tlie [patient lies on a bed or couch with his arm 
stretched out. The sphygmomanometer is placed beside his arm and on the 
same level. The sphygmomanometer consists of a mercury manometer and 
a collapsible bag in a band for encircling the arm or limb used. A pump 
attached to the bag has a valve which when closed retains the air pumped 
into the bag, and when open releases it. 

This pneumatic band is wound round the arm above the elbow; it is 
inflated by pumping, the operator palpating the radial artery at the widst 
notes the level of the mercury at which the pulse disappears. He then 
releases slightly the pressure on the arm, places his stethoscope on the 
radial artery just below or at the bend of the elbow, and inflates the bag 
until the mercury registers 5 millimetres above the figure noted at tiie first 
reading. The flow of blood into the artery is obliterated and the air in the 
bag is then slowly released until the first sound is heard — this is the systolic 
sound and the level of the mercury at this point gives the systolic pressure. 
The operator continues to release the pressure, listening carefully, the 
sound increases in intensity, reaches a maximum and then a first soft sound 
is heard followed by a second soft sound — this is the diastolic sound. The 
level of the mercury gives the diastolic pressure. 


RESPIRATION 

Respiration consists of an inspiration, expiration and pause. By means 
of respiration oxygen is taken round the body, carbon dioxide is collected 



42 TEMPERATURE, PULSE AND RESPIRATION 

and excreted. Respiration is involuntarily performed. It is brought about 
by stimulation of the respiratory centre in the medulla oblongata due to 
the presence of carbon dioxide in the blood, representing the need of the 
body for oxygen. The centre thus stimulated causes impulses to be passed 
out by the phrenic and intercostal nerves to stimulate these muscles, and 
this results in a rhythmical rise and fall of the chest walls accompanied 
by descent and ascent of the diaphragm, alternately enlarging and de- 
creasing the size of the chest as air passes in and out. 

Normal respiration is rhythmical, quiet, regular and comfortable. 
The rate varies with age, and sex. 

R^aie, A newborn infant — 40. 

At 12 months — 30. 

From 2 to 5 — 24 to 28. 

An adult — from 16 to 18, slightly quicker in a woman than in a 
man. 

It may be increased in a normal person by taking exercise, and by any 
excitement or emotion. It is decreased during rest and sleep and when 
fatigued. 

In abnormal conditions it is increased in most febrile states, in all chest 
diseases, in many states of toxaemia, and after the administration of drugs 
which stimulate respiration such as atropine. It is decreased in injuries to the 
brain, in most conditions of coma, and after the administration of hypno- 
tics, particularly opium. 

The ratio of the respirations and pulse rate is normally 1- 4. This alters 
ver)" considerably in certain chest diseases, particularly in pneumonia, 
when the ratio may be as low as 1—2; for example, a patient’s pulse may be 
100 and the respiration rate 50. 

In taking the respiration, the nurse should note the rate, character 
regarding its depth, regularity and rhythm, and any discomfort which 
may be apparent. She must be careful that the patient is not conscious of 
what she is doing, and she should try and divert his attention from him- 
self. It is quite easy to count the respiration rate with the hand on the pulse, 
having a watch or pulsometer in such a position that the movements of the 
patient’s chest might be seen at the same time. She should count for a full 
minute. 

It is also important to notice where the movements occur during 
respiration. Abdomi no- thoracic breathing is the normal. When the dia- 
phragmatic action predominates, the epigastrium will be seen protruding 
during inspiration. In cases of diaphragmatic paralysis this movement is 
absent, and, instead of protrusion, recession occurs here. In acute abdomi- 
nal conditions thoracic movement will predominate, as the abdomen is 
held rigid; and conversely, in painful conditions of the chest, abdominal 
movement predominates. The nurse may be of great assistance to the 
physician by observing and reporting on these points. 

Abnormal respirations. The rate naay be abnormally quick or slow. 
As a rule the depth is shallow when the respirations arc rapid, and slow 
respirations are usually deep in character. 

The rhythm may also vary. Sighing is manifested by long, slow inspiration 
followed by a rapid expiration. It occurs in shock, collapse, and in certain 



RESPIRATION 43 

emotional states. Tawning indicates a condition of syncope. In pneumonia 
the pause at the end of expiration is short and terminates in a grunt. In 
Cheyiu-Stokes' s breathing the rhythm is very irregular. The respiration begins 
fairly normally and increases in depth and vigour until a maximum is 
reached, then gradually fades until a period of apnoea occurs, after which 
the cycle commences again. 

Inverse, In this type of breathing which is most frequently met with in 
children, a pause occurs between inspiration and expiration, instead of, as 
in the normal, after expiration. 


DYSPNOEA 

In dyspnoea the breathing is difficult and noisy and in most instances 
it is painful or at least uncomfortable. The difficulty may affect inspira- 
tion or expiration, or both acts may be difficult. In orihopnoea the difficulty 
is usually relieved when the patient sits up. Apnoea is a feature of some 
types of dyspnoea and indicates that there is absence of breathing for a 
short period. 

Causes. Dyspnoea may be due to a variety of causes, including 
pressure or obstruction in the respiratory passages such as a tumour, the mem- 
brane present in croup, the presertce of blood, mucus or a foreign body, 
the occurrence of oedema in congestion, for example, of the larynx, and 
stricture which may follow an injury. 

The ohstruction may he due to pressure on the trachea or larynx as in hanging 
by strangling, the presence of a mediastinal tumour, an aneurysm of the 
aorta or an enlarged thyroid gland. Dyspnoea may also be due to paralysis 
of the respiratory muscles, to diminished lung capacity as in emphysema, bron- 
chiectasis and advanced pulmonary tu])erculosis; to cardiac failure for any 
cause, most often seen in diseases of the heart and acute lung diseases — 
pneumonia for example. 

Varieties. Whatever tlie cause may be, certain varieties of dyspnoea 
are described. The expiratory grunt of discomfort met with in pneumonia has 
already been mentioned. When there is obstruction in the air passages 
and it is difficult to inspire, breathing is stridulant, the passage of air giving 
rise to shrill whistling and sometimes to crowing sounds. 

Stertorous breathing is jerky and snoring in character, and occurs in coma. 
Wheezing and rattling noises occur when the air is forced through fluid as 
in the later stages of bronchitis. (Gtu ynr-Stokes’s and the inverse type of 
respiration have been mentioned under disorders of rhythm.) 

Nursing. Whenever possible, patients suffering with dyspnoea should 
be propped up in bed in the erect sitting position, taking care to see that 
they are entirely supported, and that support is provided for the arms and 
head. The head support should permit of the patient inclining his head 
to either side if he wishes to do so. Some means should also be provided 
to enable him to lean forward, such as a bed table on which he can place 
his arms in order to fix his shoulders when the extraordinary muscles of 
respiration are used. These include the trapezius and stemomastoid which 
help to fix the top of the chest and the scaleni and quadratus lurnborum 
which fix the lower part of it. 

The patient's wants should be anticipated and he must be spared every 
possible effort; when fed or given drinks, only small quantities should be 



44 TEMPERATURE, PULSE AND RESPIRATION 

allowed at a time; he should be given frequent rests during a meal as 
eating and swallowing are a great effort in these cases. This is one of the 
conditions in which it would be most inconvenient to take the patient's 
temperature in the mouth. 

All irritation and excitement must as far as possible be prevented, and 
in attending to patients with dyspnoea the nurse should be particularly 
quiet and calm of manner, not hurried or hustled in the least, and she 
must move him very gently. In anticipating his wants she will not need 
to ask him any questions — talking is specially difficult for him. 

Again, she will see that he does not have many visitors, and those who 
come should be warned that he finds it difficult and tiring to talk, and only 
those who can be trusted to sit quietly at his side or who will tell him little 
interesting items of new^s, not requiring answers, should be encouraged to 
visit such a patient. 


CYANOSIS 

Owing to the defective oxygenation of the blood due either to the 
existence of cardiac failure, as in heart disease and pneumonia, to inter- 
ference with the mechanism of respiration either as the result of obstruction 
in or on the air passages, or to embarrassment of the movements of the 
chest, many patients with dyspnoea are cyanosed. 

Cyanosis may be very marked, the patient being lividly blue; or it may 
be slight, when perhaps it will first be seen in the lips, at the tips of the 
ears or the ends of the fingers and toes. 

As a rule the presence of cyanosis in diseased conditions indicates con- 
gestive heart failure and calls for the administration of oxygen for its 
immediate relief. 



Chapter 3 

The Toilet of the Patient 


Bathing adult patients and infants — Care of the mouth — Care of the head — 
Prevention of bedsores — Giving bedpans and urinals 

BATHING ADULT PATIENTS AND INFANTS 

O ne of the first nursing duties with which a junior probationer may 
be confronted is the bathing of a patient either in bed or in the 
bathroom. She may or may not have been responsible for the care 
of the patient on admission; but she should be familiar with this procedure 
and also with the observations of a patient’s condition described on pp. 
23~*25. In many hospitals it is the rule that all new patients must be 
bathed in bed, and this is insisted on, partly because those who are 
responsible for the making of hospital rules realize the value of the obser- 
vation of a patient during the process of bathing — the whole of his body 
can be observed and handled, thus providing excellent opportunities for an 
intelligent nurse to make many observations which may be of great value 
in the diagnosis and subsequent treatment. 

During his stay in hospital a patient should be bathed every day, either 
morning or evening. 

It is important to work firmly, steadily and evenly when washing and 
drying a patient; a light touch is apt to be irritating, a patient likes to feel 
that he has been washed and he likes to be well dried. If only nurses could 
be persuaded to do so, it would be an excellent plan if each would submit 
to be bed-bathed by her other nurse friends, in order to learn what it feels 
like to be washed by another — how to do it and, furthermore, how not to 
do it. 

Articles required for bathing a patient in bed (see fig. i8, p. 146). 

2 bath blankets, warmed if possible. 

I bath towel, i face towel and i small towel for the back. 

2 washing cloths, one for the face, neck, chest and arms, and the other 
for the abdomen, lower limbs and back. 

Tow to be provided for the initial washing of the genitals. 

Soap and nailbrush. 

Nail scissors, brush and comb, and a receiver to receive the cut nails, 
and some swabs moist with methylated spirit to clean the edges of 
the nails. 

Water in a basin, comfortably hot, and a jug of boiling water by which 
it can be heated from time to time unless arrangements can be made 
to change the water during the washing process. 

In addition, articles should be supplied for the toilet of the mouth, and 
if the patient is helpless articles for mouth cleaning will be needed: if he 
can help himself, a mug, toothbrush, paste and bowl may be given to him 
and he may clean his teeth and rinse out his mouth for himself. 

Articles for routine attention to the back. 


45 



46 THE TOILET OF THE PATIENT 

Glean clothing, shirt, pyjamas, bedsocks, which should be warming on a 
radiator near by. 

The nurse should inspect the bed to see whether clean sheets will be 
required and if necessary supply these. 

A pail for soiled clothing. 

The nurse should inquire if the patient wishes to use a bedpan before 
the treatment begins, close the windows and screen the bed, placing a 
chair at the foot of the bed, and removing the top bedclothes, as in making 
a bed (see p. 76). She then places one of the bath blankets immediately 
over the patient, rolling the second underneath him, and removes his per- 
sonal clothing. 

The washing is performed in the following order. The face, neck and 
ears are washed and dried. The chest and arms are next treated and the 
patient is allowed to swill the soap off' his hands by dabbling them in a 
basin of water which the nurse holds conveniently near him. The lower 
part of the chest and abdomen and sides of the body are best done by 
working under the blanket without exposing the patient. The umbilicus 
must be cleaned and carefully dried. 

The lower limbs are washed separately. Then the patient is turned and 
his back thoroughly washed and dried; the genital region is most easily 
washed from this aspect; tow well soaked and soaped is used to wipe the 
parts down first, and then placed in a receiver provided for that purpose 
as it must be burnt. If the patient is a male, he does this for himself, if 
possible, and is then handed a well-soaped washing cloth and finally a 
clean rinsed one. The towel provided for the back is used for drying the 
genitals. The routine treatment of the back, as described in the prevention 
of bedsores, is then carried out. 

The nails may be attended to during the bath, cutting them, receiving 
the scraps of nail into a kidney dish, and if necessary cleaning the parts 
around the nails with small swabs moistened with methylated spirit. The 
soles of the feet may be very grimy, requiring the use of the nailbrush, in 
which case the nurse should scrub firmly and not irritate the patient by 
tickling. The mouth and hair are next attended to before the bed is remade 
The patient’s clean clothing is put on, the bed made, he is inspected to see 
that he has not lost heat, and if necessary a hot water bottle is supplied, 
a drink is given in most cases, and then the articles used should be cleared 
away, the windows opened and the screens removed. 

Bathing a patient in the bathroom. The room must be prepared 
first, windows closed, the bath half filled with water, running the cold 
water in first, then the hot. The water should be w^cll stirred up and tested 
with a bath thermometer; it should not be hotter than 100^ F.; the bath 
mat should be arranged, the patient’s clean clothing and towels placed 
ready on the radiators, and the soap, washing clotlis, nailbrush and towels 
put comfortably within reach. The key should be removed from the hot 
water tap so that the patient cannot turn this on; a bell must be within 
reach of the patient and it should not be possible for the bathroom to be 
locked or bolted from the inside, though a screen can be placed round the 
bath for the comfort of the patient. 

The nurse will bathe a female patient, paying attention to the points 
described in giving a blanket bath. For a male patient an attendant will 
be rcquiicd unless the ward sister considers this unnecessary, in which 



BATHING ADULT PATIENTS AND INFANTS 47 

case he bathes himself and, after he has returned to bed, tlie nurse takes 
pains to sec that he is quite clean, for example, with regard to the umbilicus 
and his feet particularly. 

Bathing a small infant. Quite a number of articles are required for 
this purpose, as an infant is a very helpless, delicate creature, and its skin 
and little orifices require special care. 

The following articles will be needed in addition to clean baby clothing 
and napkin (see fig. 19 p. 147). Boracic swabs or sterile wool with boracic 
lotion for cleaning the eyes, nose and ears. Squares of soft handkerchief 
linen, and glycerine of borax for the mouth. 

A baby bath of water, temperature of 99° F. A mild soap — no wash- 
cloths need be provided as the nurse uses her hands. Soft towels, one on 
the nurse’s knee, and one with which to dry the baby. Some sisters use 
powder to ensure proper drying of the skin, though others consider the 
skin can be adequately dried without the use of powder which tends to 
cause hai'shness and cracking. 

If the baby is a very tiny infant and is still wearing a binder a needle 
and thread are required, with which to stitch up the clean binder that 
will be put on. In this case also, a dressing for the cord will be required. 
A camelhair brush should be provided for doing the baby’s hair. 

When everything has been collected, and the bath has been placed 
before a fire if one is available — the fire being screened so that the rays 
of heat do not fall direct on the infant’s body — the windows of the room 
should be closed, and the nurse seats herself on a low stool of convenient 
height, with a screen behind her to exclude draughts if necessary and, 
wearing a mackintosh and soft flannel apron, takes the baby on her lap and 
undresses him. Wrapping him in one of the towels, so that his arms are 
gently restrained, she washes her hands, and first gently swabs the eyes, 
nose and ears with the wool swabs, and then washes the infant’s fac e with 
a piece of the soft handkerchief linen, moistened in the boracic lotion, 
drying it with a second dry piece. She then turns the baby so that its head 
lies over the bath of water (as in fig. 20 p. 148), and placing her left hand 
on the back of the shoulders, with thumb and finger separated, she sup- 
ports the occiput and, holding the infant’s head in this position, soaps the 
top and back of the head with her right hand, and rinses the soap off with 
the same hand, lifts the baby back on to her lap, and dries the head gently 
but thoroughly with a soft bath towel. 

She then uncovers the baby’s body as he lies on her lap, and using both 
hands soaps the body all over, back, front and sides, arms and legs, passing 
her hands well into all the crevices. She now places her left hand at the 
back of the shoulders supporting the occiput as before, and with her right 
hand under the buttock lifts the baby over the bath and lowers him into 
the water (as in fig. 21, p. 148). She places the infant in the bath and con- 
tinues to support his head and shoulders with her left hand in order to 
keep his head out of the water. She swills water over his body to remove 
all soap, and lifts him back with the same movements that were used 
when placing him in the water, placing him on his face on her lap, on one 
of the bath towels. She folds the towel up over his back and dabs him dry, 
paying special attention to see that all creases and crevices arc thoroughly 
dry. If the baby clothes arc open in front she can place them in position 
on his back as he lies on her lap, before turning him over to complete the 



48 THE TOILET OF THE PATIENT 

toilet of the skin of the front part of his body. He is then lifted bodily over, 
clothes and all, and put to lie on his back. In order to keep him quiet and 
good he may now be given a square of soft linen soaked in glycerine of 
borax or in sterile water. He sucks this and no further attention will be 
needed for the mouth of a normally healthy infant. 

If the cord has not separated it should then be dressed, and the baby 
clothes fastened in front. He is then dressed, his napkin fastened, and his 
toilet is now completed. A tiny infant should be bathed once a day, prefer- 
ably in the morning. An older infant, in his second year may be bathed 
twice a day. Premature babies should not be bathed at first, but should be 
anointed with olive oil. 


THE CARE OF THE MOUTH 

The care of the mouth is an important measure as most patients who 
are in the least dehydrated cither as a result of a rise in temperature, 
septicaemia or toxaemia have dry, dirty mouths. 

The articles required are best prepared on a small tray (see fig. 22, 
p. 149) which, if frequent treatments are required for one patient, may be 
kept covered and left ready for use at the bedside. 

A bowl of antiseptic swabs. 

Artery forceps with which to grip the swabs when using them so that they 
cannot be swallowed or come off the forceps in the mouth. 

Dissecting forceps^ for removing the used swabs from the artery forceps. 

Lotions. Some substance to dissolve mucus, such as sodium bicarbonate 
solution, or a solution of borax, is invariably used first. A lubricant, such 
as glycerine or paraffin to which a little lemon juice may be added, moistens 
and removes crusts, the lemon juice increasing salivation. An antiseptic 
lotion such as glycothymoline, with which the mouth will be swabbed 
after cleansing or, in the case of a patient able to help himself a little, may 
be used as a mouth- wash. 

A receiver for the soiled swabs, and one for the mouth- wash. 

Orange sticks^ with which crusts and particles may easily be removed 
from between the teeth. 

Pi soft toothbrush may sometimes be used by the nurse and will always 
be usc^ by the patient if he can help himself. 

A small towely a piece of jaconet or a square of linen may be provided 
to put under the patient’s chin, 

A lotion containing antiseptic in which to place the patient’s dentures 
should also be provided. 

Procedure. Having protected the bed if considered necessary, and 
explained to the patient what is to be done, the mouth should be inspected 
and the treatment begun in some definite order. 

Dentures will be removed first, placed in the basin provided and taken 
to the sluice room where they may be cleaned in warm water, using a 
soft nailbrush, replacing them in a little warm water ready for use again. 

It is very comforting if the mouth is rinsed or at least swabbed with a 
liquid preparation before the cleansing by rubbing is commenced. In 
preparing the swabs, see that they are fimtly gripped by the forceps; 
moisten the lips and tongue with the first solution, clean the teeth with an 
up and down movement, paying special attention to the insides, using the 



THE CARE OF THE MOUTH 49 

orange stick to remove particles from between the teeth; the insides of 
the check should receive careful attention, as also the gums, tongue and 
roof of the mouth, taking care when touching the two last named parts not 
to make the patient ‘gag.’ If this should happen, allow him to rinse his 
mouth out if possible and thus obtain a little rest for fear lest he should be 
made sick. 

Great care must be taken to remove all sordes and crusts very gently 
as sometimes there is a tendency for parts underneath to bleed. Each swab 
should only be used once. It should be dipped in the solution and then 
pressed against the side of the gallipot to prevent its being dripping wet, 
and the various lotions are used in the order previously indicated. After 
the treatment the patient should be given a drink, either water or weak 
lemonade. In the case of a patient on milk feedings, the mouth will be 
cleaned before the feeding and a small drink of water follow the feeding 
in order to prevent milky particles from remaining in the mouth, remem- 
bering that sordes consist of dry mucus and saliva and decomposing food, 
which form a favourable collecting ground for micro-organisms. 

In cleaning the mouth the nurse should make very careful observation 
of the condition of the patient’s tongue. When thickly furred, it is a good 
plan to smear it with a little white vaseline or liquid parafin before cleans- 
ing, as this helps to soften it. The same precaution might be taken with 
regard to the lips if they are very hard and badly cracked. 

All swabs and materials used for cleansing a mouth should either be 
destroyed by burning as in a private house, or treated as other soiled 
dressings would be in a hospital. The articles used, including forceps, 
must be washed and resterilized as the tray should always be ready for use. 

It seems unnecessary to say that a nui*se should be very gentle in hand- 
ling a patient’s mouth. Sometimes when it is very sore it may be better 
for her to use squares of linen wrapped round her finger instead of swabs 
on forceps, that is, provided there is no danger that the patient may bite 
the finger. 

In some cases of insane and delirious patients a mouth gag may have 
to be inserted whilst the mouth is cleaned. 

The nose should receive attention at the same time as the mouth, as it 
frequently becomes full of crusts and dried secretion. It is very important 
to keep the nose clear. It should always be kept free of discharge, and the 
edges of the mucous membrane could be smeared with a bland ointment 
whenever it appears at all sore. 

Routine cleansing of the mouth in patients who are less seriously ill and able 
to help themselves forms part of their personal toilet and is usually carried 
out twice a day; the patient should be propped in a comfortable position, 
have a towel placed under his chin, and a receiver arranged to collect 
the fluid from his mouth; the nurse should put some paste or powder on 
his toothbrush, and hand it to him to use, renewing as necessary. 

In cleaning a baby’s mouth, it is very important to remember that 
in the normal baby it docs not require cleaning, as the baby should be 
given enough water to drink to keep the mouth clean, tn the case of very 
ill babies, it may be necessary to make some attempt at cleansing, but rub- 
bing or friction cannot be used. 

A rare complication^ occasionally met in artificially fed babies, is thrush^ 
in which small white flakes appear on the mucous surfaces of the mouth. 



50 THE TOILET OF THE PATIENT 

This will be found to respond to cleanliness, both of the mouth and the 
utensils used, and does not usually call for any handling by the nurse. 

Complications which may occur if the mouth is neglected. 

The first is the collection of the sordes and crusts on the lips and teeth, 
cracking of the lips and furring of the tongue, and the occurrence of 
herpes at the corners of the mouth. 

A condition of dirty mouth, which will invariably have an odious taste, 
unless it has destroyed the sense of taste altogether, leads to nausea and the 
refusal of food. This in turn lowei^ the resistance of tlie patient and inter- 
feres with his progress towards recovery. As the mouth communicates 
with so many other parts of the body infection may spread, for example, 
to the stomach, giving rise to gastritis; to the lungs, causing inhalation 
pneumonia; by the passing of infection to the middle ear otitis media may 
arise; by the posterior nares rhinitis may be set up and infection spreading 
from this part to the meninges may cause meningitis. Sepsis may travel by 
Stenson’s duct and infect the parotid glands or by way of the local lym- 
phatics and bloodstream giving rise to adenitis and tonsillitis. 


CARE OF HEAD AND HAIR 

On the admission of every patient a nurse inspects the head to see that 
it is clean and free from lice. 

In routine care of the hair, it is brushed and combed twice a day. In 
doing this the nurse must avoid giving pain; the hair should be held firmly 
at the roots and the ends combed first; when all Lingles have been removed 
the hair may be combed from root to end. If hair is badly tangled, moisten- 
ing it with a little spirit helps and the tangled part should be gently teased 
with a comb until the individual hairs are loosened and it is free. Long 
hair should be arranged in two plaits, one each side, so that the patient 
does not lie on it. 

A nurse should notice if the scalp is clean and free from dandruff. Any 
dandruff that remains after brushing the hair can be removed by rubbing 
with a little spirit diluted with water. It is of great importance in surgery 
of the head to keep the scalp quite free from any scurf or scales. If a head 
is badly covered with dandruff, the application of moist powdered borax 
well rubbed into the scalp before washing will usually be effective in 
removing it. 

Fine -combing the head for the removal of lice. The following 
articles should be collected (see fig. 23, p. 149): 

Mackintosh cape^ to protect the patient's shoulders, and a drawshect to 
place over the pillows at tlie top of the bed. 

Dressing comb and fine tooiheomb in a receiver containing some antiseptic 
such as 1-20 carbolic. 

Bowl containing white wool swabs, cither moist or dry. 

Receiver for the soiled swabs. 

The head louse, which varies in colour, deposits nits on the hairs which 
become fixed to them by means of a sticky film; nits will be found near 
the roots of the hair, particularly in the warm spots at the nape of the neck 
and behind the ears, and it is therefore advisable, when fine-combing the 
head, to part the hair and begin at the nape of the neck. 



GARE OF HEAD AND HAIR 5I 

When combing, the comb should be drawn through the hair close 
to the head; and, in order to prevent any lice or particles of scurf from 
dropping about, the underneath of the comb should be protected by a 
moist swab, held in the left hand, as it is drawn out at the ends. Do the 
parts behind the ears next, and finally when these are clear comb the whole 
head systematically, working from front to back, taking small strands 
separately, until every part has been covered. 

In treating a verminous head it is necessary to destroy both nits and lice. 
Lauryl thiocyanate in a 25 per cent, concentration in a refined paraffin 
is rubbed into the scalp — the head is thoroughly treated, the hair being 
parted and the preparation rubbed into the scalp. The hair is washed 
alter 10 days. 

Alternatively some solution may be employed, either sassafras oil, 
para {fin, weak lysol, carbolic 1-40 or industrial spirit 7 parts in 3 parts of 
water. In every case the hair must be well saturated. The one important 
])oint is the complete saturation of every hair of the head. The hair is then 
wound round the head and covered by a compress of a single layer of lint. 
The flufiy side of the lint sliould be next to the head, as this helps to 
entangle the stupefied lice as they attempt to escape from the carbolized 
liead, I'his is then covered with a piece of jaconet and bandaged on, either 
using a roller bandage (capelinc), or a triangular bandage. The pillow 
nearest the head should have a jaconet casing whilst this is worn. It is 
usual to carry out this treatment overnight, and to wash the head first 
thing in the morning. 

NITS 

It is always possible to tell how long a head has been verminous by the 
position of the nits, because these are deposited at the roots of the hair and, 
as the hair grows about an inch a month, the time of infection can easily be 
calculated. Nits cling firmly to the hair and are difficult to remove — 
fjrobably the best methods are to moisten the hair with olive oil or wash 
Ji with a soap and borax solution and then comb it ^\^th Sackefs nit comb. 

WASHING A PATIENT'S HAIR IN BED 

I his is not such a formidable task as once upon a time it was, since so 
many women today luive short hair. If the patient can move about at 
all, it is comparatively easy to wash the head as she leans forw^ard over a 
basin, or backward with the basin arranged behind her; but when the 
bair is long, and the patient comparatively helpless, a method which Is 
drscribed below had better be used (see fig. 24, p. 150). 

The articles required are: mackintosh cape to protect the patient’s 
shoulders, and large mackintoshes to protect the top of the bed. 

Towels^ to dry the hair, and a small face towel with which the patient 
can keep water from her face and out of her ears; unless she is helpless, 
and then it is better to put a little cotton wool into the ears in case of 
accident. 

A large bowl in which to wash the hair. 

A pail for dirty water. 

A jug of prepared soap solution^ with which to lather the head, and jugs 

warm waiter for waging and rinsing purposes. 

Brush and comb with which to complete the toilet of the head. 



52 THE TOILET OF THE PATIENT 

M6thod. Unless the top of the bed has a movable back, which can be 
taken out, and the treatment performed from behind the head of the bed, 
it is necessary either to draw the mattress down over the foot of the b^, 
or to roll it under at the top, so that the basin can be placed on the wire 
mattress. A long mackintosh is used to protect the mattress at the top, and 
the bowl is placed on it. The pail is placed conveniently at the side of the 
bed. When all articles are ready, the mackintosh is arranged over the 
patient’s shoulders, and she is drawm to the top of the bed, and her head 
held over the basin by a hand placed under the occiput. With the other 
hand the nurse wets the hair with warm water, and then pours small quan- 
tities of soap solution over it, rubbing well with her hand or hands to 
lather the hair and cleanse the scalp. The first lather is rinsed off and the 
treatment repeated. The second rinsing should be very effective and leave 
the hair quite free from soap latlier. The nurse then presses the hair close 
to the head from roots to ends in order to squeeze as much water as possible 
out of it, wrings the ends and coils them up on top of the head, covers it 
turban fashion with the bath towel, removes the mackintosh from the 
top of the bed and the mackintosh from the patient’s shoulders (replacing 
this by a bath towel), places the patient comfortably with her head on a 
mackintosh-covered pillow and clears away the articles she has used. She 
then proceeds to dry the hair by rubbing with the bath towel until quite 
dry. Many hospitals supply electric hair dryers for this purpose, but if 
one of these is not available, or if continued rubbing of the head would 
be injurious to the patient’s condition, very long hair might be spread out 
behind the patient on a towel over several hot water bottles. 


BEDSORES AND TROPHIC SORES 

Bedsores may occur while lying long in bed. At first the skin is red- 
dened, the part looks sore and is tender; and as the condition progresses 
the skin becomes abraded, superficial tissues are destroyed and ulceration 
results. The surface is now covered with an exudate which, if the condition 
progresses still further, becomes a serous discharge, and as ulceration 
deepens, sloughing of the central parts follows and, as a slough is a 
foreign body, the parts are now surrounded by a zone of inflammation, 
and take on the characters of any other typical ulcer. 

Patients liable to bedsore arc those who for any reason may have to lie 
in bed for a long time, particularly if emaciated, paralysed, incontinent, 
old, senile, or mental, and those suffering from any nutritional disorders 
such as certain nervous diseases, heart, lung and kidney disease, and any 
bedridden cases where nursing attentions are neglected. 

Causes. The causes of bedsore may be divided into local causes, and 
predisposing general causes. The type of patient liable to bedsore suggests 
the latter group. 

Local ^ causes include pressure, which may be merely the weight of the 
patient’s body as it lies on the bed, or else due to the fact that the bed w 
too hard or too lumpy, or the pressure of the bedclothes too heavy as they 
rest on the patient’s body. 

Dampness is a potent source of bedsore — some people go so far as to say 
that a bedsore cannot arise if the parts are always dry — and moisture may 
be the result of perspiration, or of the soiling of bedclothes by excreta or 
discharges. 



BEDSORES AND TROPHIC SORES 53 

Friction may be a cause of bedsore, as the skin frequently irritated first 
becomes reddened and is then rubbed off. This may occur as the patient 
moves about on the bed, or as he moves his legs up and down under the 
top bedclothes and thus causes friction over the knees. 

Creases and crumbs, or other foreign bodies in the bed, increase pressure 
locally, where they lie and press into the tissues and so cause red marks 
first, and at last give rise to soreness. 

Parts liable to bedsore. Starting at the top and working downwards 
over the entire body: the back of the head may become sore, particularly in 
the case of infants and children who continually rub their heads, or who 
arc given to head banging; the shoulder blades, which are prominent, par- 
ticularly in emaciated persons; over the vertebral spines, throughout the 
entire extent of the column and over the sacrum and coccyx at the end of the 
column; and the backs of the heels as they lie heavily on the bed — all of 
these protuberant parts of a human body that lies long in bed may become 
liable to bedsores. 

In patients who lie on the side, bedsores might occur over the great 
trochanters, on the outer aspect of the knees, between the knees and ankles as they 
may rub together when in this position. Soreness over the knees has already 
been mentioned as occurring in persons who restlessly move their legs up 
and down in bed. The elbows are very apt to become sore in people who lie 
on the back or who lean on their elbows for reading and eating. 

Prevention of bedsores. Certain routine local treatment must be 
applied as often as necessary to all patients who lie in bed, in order to 
prevent any manifestation of redness on any parts that are subject to pres- 
sure. In the majority of hospital patients this treatment is carried out twice 
a day, and following any attention to the back such as after a surgical 
dressing in this area, or after sponging a patient. 

The requisites for routine attention to the back (see fig. 25, p. 151): 

A bowl of water. 

Patient’s soap and special washcloth for back, or a wad of tow may be 
used. 

Dusting powder to dry the parts thoroughly. 

Special towel kept for the back which will be laid on the bed during the 
treatment, and used for drying the genitals. 

Method. Thoroughly wash the back, using soap and a pad of tow^ or the 
washcloth, and rubbing fairly vigorously; do not dry, but lather the palm 
<^f the hand well with soap and rub this into the skin of the back for a few 
niinutcs using circular kneading movements, so that the tissues under the 
skin are moved about without allowing the hand to slip over the skin; then 
rinse the soap off the skin, as if left on it may cause imtation and rough- 
ness, and dry well and then sprinkle powder on the palm of the hand and 
dab it well over the skin with gentle tapping movements which assist in 
stimulating the skin, at the same time covering it with powder. Do this 
until the back is very thoroughly dry. 

Special care necessary with patients who are paralysed and incontinent. Every 
effort must be made to keep incontinent patients from lying on a wet sheet, 
since if they do the skin of the back will always be sodden and cold, and so, 
deprived of its blood supply, will rapidly become very sore. In some of 



54 the toilet of the patient 

these cases the urine is irritating in character and may cause soreness and 
excoriation of the skin unless contact with it can be adequately prevented. 
In such circumstances it is advisable to protect the skin by rubbing in 
a small quantity of ointment, of a greasy nature, such as a mixture of 
zinc and castor oil; but, when the routine treatment is performed, great 
care must be taken to wash off all stale ointment, and for this very hot 
water will be needed and a good soap lather in order to prevent inter- 
ference with the functions of the skin by blockage of the pores. The routine 
treatment described above is then carried out, but instead of powdering 
the skin a small quantity of ointment is well rubbed in. The skin is water- 
proof and is oiled naturally by its own secretion, sebum^ and the ointment 
applied may therefore be regarded as increasing the natural protection 
of the skin by preventing the urine from soaking in and thus enabling it 
to run off as w’ater runs off a greasy surface. 

In the prevention of bedsores the importance of the conditions which 
predispose to soreness have to be taken into consideration. 

Prevention of Pressure. Pressure is probably the most potent cause of bed- 
sore, and prevention needs imagination and ingenuity on the part of the 
nurse. A patient who shows any signs of soreness of the back should if 
possible lie on one or other side alternately for short intervals. If this is not 
possible then the back must be relieved of its pressure in some other way, 
such as by the use of woollen ring pads or air and water ring cushions. 
In applying these the edges of the ring must be bevelled, otherwise the 
tissues of the back sagging through the hole will become oedematous and 
sore round the margins. This sagging oedematous mass, deprived of blood 
supply, is readily injured. 

Patients sometimes are nursed on full size water or air beds, or are sup- 
plied with water cushions or pillows from the commencement of their ill- 
ness, In patients who are suffering from some condition known to devit- 
alize the tissues very markedly, or to result in marked emaciation, such as 
in the first case, a fractured spine, for example, and in the second instance, 
serious pulmonary tuberculosis, it is good nursing to supply these articles 
from the outset, as the treatment of bedsores is primarily preventive. 

Moisture. A moist skin soon gets cold, and a cold skin interferes with 
blood supply to the part, which therefore, easily devitalized, soon becomes 
sore. It is a comparatively easy matter to keep a patient quite dry. The 
sheet should be changed often enough, and if possible the patient should 
be washed and powdered locally after the use of the bedpan. In cases 
where there is frequency of micturition it may be impracticable to wash 
each time, but powdering should never be omitted. 

Friction. In the use of utensils and appliances all friction should l>e 
avoided. For example, a chipped enamel bedpan may be a source of fric- 
tion, but this should never be used. 

Patients who are restless, but in a condition to have matters explained 
to them, should be told that frequent rubbing gives rise to soreness and is 
inadvisable. If there is a tendency to rub the knees and ankles together, 
woollen ring pads might be bandaged over the prominences. The same 
measures might be taken with patients who insist on moving their legs up 
and down in the bed and so rubbing the skin off their knees. In patients 
whose skin is very tender, so that the slightest friction seems to injure it 
the limbs should be wrapp>ed in cotton wool bandages; but the nurse must 
remember that these have to be moved daily for careful inspection and 



BEDSORES AND TROPHIC SORES 55 

washing of the skin. Bedcradles can be used to remove the weight of the 
bedclothes if these are a source of irritation. 

Curative treatment of bedsores. Whilst emphasizing the doctrine 
that bedsores should never occur, we are nevertheless faced in some in- 
stances by the necessity of treating them. Once the skin is abraded, every 
care must be taken to prevent the entry of micro-organisms — such a wound 
is therefore treated with all aseptic precautions. During the early stages 
probably stimulating healing dressings, combined with a lubricant, to pre- 
vent the dressing from sticking to the part, may be employed. Examples of 
such lubricant are liquid paraffin, flavine and tannic acid, as would be 
employed in the treatment of a bum. When the surface is covered with 
exudate or discharge, it may be sufficient to clean this off with peroxide 
of hydrogen, followed by the use of an antiseptic dressing; or more drastic 
measures may be needed to clean the parts, such as the application of 
fomentations. Whenever the surface is raw and red, as may be seen in bed- 
sores that occur rapidly, or in others where sloughs have been removed by 
hot applications, a highly stimulating dressing such as red lotion, contain- 
ing zinc sulphate, may be used. Frequent change of dressing may help, 
many of the aniline dyes are very useful in this respect, such as brilliant 
green and scarlet red — these are antiseptic and stimulating and do not act 
as irritants. The application of elastoplast is valuable where frequent 
change of dressings is not required. 


TROPHIC SORES 

This condition may be aggravated by any of those described as possible 
causes of bedsq^'c. But a trophic sore is one which occurs because the nutri- 
tional nerves arc affected. Such a condition may occur in injuries to the 
spinal cord, in anterior poliomyelitis and in peripheral nerve lesions, and 
may also be associated with other diseases of the nervous system and occur 
under conditions of severe toxaemia. 

A trophic sore may begin very much like a bedsore, or it may first appear 
as a patch of discoloration of the skin, a purpuric patch or a blister. 

Prevention and treatment. The precautions described in the pre- 
ventive treatment of bedsore apply here. Very careful watch should be 
kept of any patient who could be suspected, by reason of hb condition, of 
a tendency to develop trophic sores, and even the slightest irritation should 
be avoided. Such a patient for example should never be rolled over to have 
his sheet or drawsheet changed, he should gdways be lifted; he should never 
be placed on an unprotected bedpan, the edge or rim of which must always 
be covered by wool, tliough an air cushion might be used for this purpose. 
Water or air beds should be utilized from the commencement of the illness; 
no two skin surfaces should ever be permitted to come together; it may be 
necessary to bandage ring pads on the inner side of the knee and over the 
inner m^leoli, and the heels should be protected in the same way. In many 
instances it is advisable to bandage the limbs in cotton wool, removing it 
twice daily and washing and powdering and carefully inspecting the skin. 

Trophic sores unfortunately may not always be preventable, they ore 
very difficult to treat, and in many cases improvement occurs only as the 
nutrition of the part is reorganized by improvement in the patient’s con- 
dition. 



56 


THE TOILET OF THE PATIENT 


GIVING BEDPANS AND URINALS 

In most hospitals the ward is ‘closed’ at regular stated times for the pur- 
poses of the sanitary round, by placing a screen in front of the ward door, 
thus indicating to visitors, including the doctors and clergy, that they may 
not enter without first inquiring if this could be arranged for them because, 
during the time the sanitary round is in progress, every patient is being 
given either a bedpan or a urinal. 

It has to be remembered, however, that in very many cases patients will 
require bedpans in between these stated times. This necessitates screening 
the bed of the patient. Some probationers think a patient is exacting if he 
asks for a bedpan at an unusual time, but if she has the right kind of 
imagination she should realize that many concessions must be made to 
sick people, and that as a general rule they only ask for these things when 
driven by necessity. Most people will suffer much discomfort rather than 
ask, and this discomfort has preceded their request. 

Most nurses perform both this and many other similarly unpleasant ser- 
vices most willingly, and if a nurse wants reward she will get it in the relief, 
gratitude and peace expressed on the face of the patient who may have 
been summoning all his courage to ask for this vessel at what he fears 
might be an inconvenient moment. 

The nurse’s sleeves should be rolled up during the performance of the 
sanitary round and she should wash and scrub her hands and forearms 
afterwards. 

When giving a patient a bedpan it should be warm and dry, and be 
carried to the bedside under a calico cover; if a round pan is used, it should 
have its lid and handle cap on in addition. If the patient can help him- 
self, that is, get himself on to the bedpan, the nurse should turn the bed- 
clothes back and slip it under his buttocks from the right side, unless con- 
traindicated, as for example when the patient has a wound on the left side. 

To place a patient on a bedpan who is unable to do much to help him- 
self, the nurse should turn the quilt and blanket down to the foot of the 
bed, leaving the patient covered by a sheet and blanket; and then, stand- 
ing on the right side of the bed, by placing her left hand under the lower 
part of the patient’s back, raise him sufficiently to slip the bedpan under 
his buttocks with her right hand. She should then feel that the pan is in a 
convenient position, neither too high nor too low, and arrange the patient’s 
pillows so that he is propped comfortably on it. In the case of a thin 
patient the bedpan might have to be padded with brown wool to effect 
this. 

For helpless patients, two nurses will be required, one at each side of the 
bed. 

To cleanse the patient. Either toilet paper, moist tow or brown wool swabs 
may be used for cleaning the patient after the use of the bedpan. If he 
particularly wishes to do so and is able he may perform this office for him- 
self; otherwise the nurse will do it. If moist swabs are used the patient’s 
skin should either be dried with dry swabs or with the ‘back towel’ pro- 
vided for drying these parts. The used swabs arc put into a receiver pro- 
vided for this purpose, as if placed in the bedpan they would have to be 
picked out by forceps before it could be emptied. If the patient has 
cleansed hims^ after the use of the bedpan he should either be given an 



GIVING BEDPANS AND URINALS 57 

Opportunity to wash his hands, or if this is not convenient — as for instance 
in a very large ward — he should be given moist swabs on which to wipe 
his fingers. The contents of all bedpans should be inspected before they are 
emptied. 

To empty a bedpan. After removing the lid and handle end and inspecting 
the contents and removing any bits of wool or other material which should 
not be put down a drain, the pan is usually inverted over a rose or up- 
ward spray, the water is turned on and this washes the contents out of the 
pan into the sluice. It should then be inspected and if not clean a mop, 
which is standing ready in disinfectant, is passed round the inside of the 
pan and through the handle, the pan again rinsed, the outside dried and 
it is then put away. 

Urinals are usually made of porcelain, glass or enamel. Glass ones are 
best, since they are easily cleaned, it is easy to see that they are clean, and 
the character of the urine in them is most easily inspected. 

A urinal is taken to the bedside covered by a calico cloth which should 
have some indication by a distinguishing mark as to which is the inside 
and which the out. 

The cloth should not be left in a prominent position such as the floor, 
except during the sanitary round when the ward is closed. On other occa- 
sions it may be placed on the rail at the head of the bed, below the level 
of the mattress, or tucked in over the side of the bedstead. In this way the 
fact that the patient is using a urinal is not evident. 

Urinals should be emptied immediately after use and rinsed with cold 
water, which is most conveniently performed by means of an inverted 
spray, and they are then placed upside down to drain. 

A nurse should always make sure whether a specimen of urine or stool 
is to be saved. She should observe the character of these in every instance 
and also any untoward symptoms, such as frequency, variations in quan- 
tity and so on. If all urine is being saved, as in a collection of 24-houi's’ 
specimens (see fig. 26, p. 151), the amount taken from the patient should 
be charted on the label provided on the bottle on every occasion. 

In the routine care of bedpans and urinals, means are taken to keep 
them clean and quite free from any deposit, such as may be the result of 
highly concentrated urines depositing urates or phosphates. Some ward 
sisters have these articles soaked for two hours in a strong disinfectant 
solution once in 24 hours; others consider that rinsing them with disinfec- 
tant after use is sufficient. In maternity and infectious disease wards they 
should be boiled. 

To keep urinals free from deposit, washing with water containing wash- 
ing soda and using a bottle brush to help remove any deposit may be 
adequate; in some cases of marked phosphaturia a urinal may become 
crusted in a very short time. Harpic^ which is a very strong cleansing mat- 
erial specially recommended for removing any deposit from the glazed 
surfaces of sanitary pans, may be used in these instances. 



Chapter 4 

Observations of Excreta and Discharges and 
Collection of Specimens 

The characteristics of normal urine and its variations in health and disease — 
The testing of urine — Characteristics of normal faeces with variations in health and 
disease — Collection and disposal of sputum and observations — Types of vomit; care 
of a patient when vomiting — Vaginal discharges, observations and nursing care — 
The collection of specimens of urine, faeces, sputum and vomit; of pus, fluid and 

secretions and of blood 

THE CHARACTERISTICS OF NORMAL URINE, VARIATIONS 
IN HEALTH AND DISEASE 

T he normal characteristics of urine are: 

Colour — pale amber. 

Odour — aromatic. 

Qjiantity — in the adult — 40 to 60 ounces. 

Reaction — ^slightly acid to litmus. 

Specific gravity — i ,0 1 o to i ,020, 

The urine should be clear without deposit — there may be a light 
flocculent cloud of mucus floating in the centre of the specimen. 

Variations in health and disease. The quantity is decreased in 
health when the amount of fluid taken is limited, or when perspiration is 
heavy as the result of exercise or excessive clothing and in hot weather. 
When the quantity is much diminished the colour becomes deeper, the 
specific gravity higher, and there may be a deposit of urates on cooling. 

The quantity is increased in opposite conditions, such as when the skin is 
acting slightly, as in cool weather, in conditions of fear and nervousness, 
when little exercise is taken, and if the diet should be low, and when the 
fluid intake is increased. In these circumstances the colour is paler and 
the specific gravity is lower. 

The normal odour varies very little during health, and the variation in the 
reaction is also slight — ^for example, it may be found to be alkaline after a 
meal rich in carbohydrates. 

The characteristics vary more considerably under conditions of disease. The quan-- 
tity is decreased in febrile conditions, heart disease, acute nephritis; in some 
cases of chronic nephritis, in some surgical diseases of the kidneys; after the 
administration of certain drugs such as opium and ergot; and in all cases 
in which fluid is lost to the body as in haemorrhage, vomiting and diar- 
rhoea, and in many conditions of toxaemia, and also when there is marked 
oedema. 

The quantity is increased in diabetes, in some disorders of the pituitary 
gland, in hysteria and other functional nervous conditions, in most cases 
of chronic nephritis, by the administration of diuretic drugs, such as potas- 
sium citrate, digitalis and mercurial diuretics, and when the int^e of 
fluid is increased. 


58 



GHARACTERISTIOS OF NORMAL URINE 59 

The colour varies with the quantity as previously mentioned. Bile colours 
the urine very dark olive green, blood renders it smoky or red, chyle makes 
it look milky. Certain drugs also alter the colour of urine; in carbolic acid poison- 
ing it is green, the administration of phcnolphthalein colours an alkaline 
urine red; santonin gives a yellow colour. 

The urine is rendered opaque by the presence of blood, chyle, pus, excessive 
mucus, and also by phosphates and urates until these have been deposited. 

The deposits normally seen in urine are urates^ which may be pink or 
white; phosphates ^ usually whitish grey, but sometimes slightly tinged by 
pink; pus^ which is very dense, lying heavily at the bottom of the glass; 
blood may be present in clots; particles of uric acid suggest a sprinkling of 
cayenne pepper over the specimen glass; excess of mucus may form a gela- 
tinous mass. 

The odour is slightly fishy when decomposition is commencing; when 
very marked the odour becomes ammoniacal. I'he presence of acetone 
bodies gives a scented urine which recalls the smell of newmown hay. The 
odour of certain drugs such as carbolic may be detected in the urine, and 
turpentine produces a pungent odour described as being like the scent of 
violets. 

The reaction may vary very considerably in disease. A concentrated 
urine is usually highly acid, and consequently irritating; urine containing 
phosphates is neutral or alkaline, and urates give an acid urine. As a rule 
the urine is alkaline in cystitis. Certain drugs are administered to effect 
alteration in the reaction in the treatment of disease — for example, potas- 
sium citrate renders the urine alkaline, and acid sodium phosphate makes 
it acid. 

As a general rule, the specific gravity is low when the quantity is in- 
creased and high when decreased; in diabetes mellitus, however, the 

f »rescnce of large quantities of sugar in the urine results in the passing of 
arge quantities with a characteristically high specific gravity. 


ABNORMAL CONSTITUENTS OF URINE 

The substances for which urine may be chemically examined by a nurse 
are protein, blood, bile, sugar, acetone bodies, pus, diacetic acid, urates 
and phosphates, the quantity of chlorides. In addition, urine may be 
examined for uric acid, the presence of red blood cells and pus cells, casts 
and bacteria, and for tJie quantity of urea, albumin and sugar; but these 
tests are not usually performed by a nurse, and are therefore not described 
here. 


EXAMINATION OF URINE 

1. Ascertain quantity from which specimen is taken. 

2. Notice colour and clearness, and presence or absence of 

deposit. 

?. — No urine should be stirred before iestingy see deposit, p, 62. 

3. Take the reaction. 

Acid urine turns blue litmus paper red and has no effect on red. 
Alkaline urine turns red litmus paper blue and has no effect on blue. 



6o OBSERVATIONS OF EXCRETA AND DISCHARGES 

Normal urine is acid. It may be alkaline after a meal, especially of 
vegetable food, in cystitis, and while taking certain drugs, such as citrates, 
etc., and also from decomposition on exposure to air. If alkaline, it must 
be made acid by a few drops of dilute acetic acid before testing further. 

4. Take the specific gravity. 

The temperature of urine should be approximately room temperature. 
The normal specific gravity is between i,oio and 1,020. 

A Low Specific Gravity may be temporary only or suggests kidney disease, 
A High Specific Gravity with pale urine suggests diabetes. See that the 
urinometer floats and stands clear of the sides of the vessel; read the 
number with the eye on a level with the surface of the urine. 

5. Examine for substances in solution. 

Protein (albumin). 

Blood. 

These may be: Bile. 

Sugar or glucose. 

Acetone. 

JV.J 5 . — The finding of one substance does not preclude the fnresence of another, 

A. Tests for Protein. 

Boiling test. 

The urine should be filtered before testing for protein. Fill a test tube 
with the urine to about i in. from the top. Boil the top of the column of 
clear urine over a naked flame (see fig. 8 ). Compare any cloud w^hich 
develops with the lower clear layer. A precipitate or cloud denotes: 

I. Proteins 
or 2. Phosphates. 

Add a few drops of dilute acetic acid. If the precipitate dissolves it is 
phosphates. If the precipitate does not dissolve it is proteins. 

Nitric acid test. 

If albumin is suspected it may be tested for by nitric acid without heat 
when the urine is clear. 



Fio. 8. 

Method of holding a test tube 
when heating the upp» part of 
a column of liquid. 



A sjpedal holder may be enmloyed when 
boiling a imall quantity of fluid in a test 
tube. 


EXAMINATION OF URINE 


6l 

Pour a small quantity of nitric acid into a clean test tube; allow a similar 
quantity of urine to trickle steadily down the side of the test tube — where 
the two fluids meet, a layer of coagulated albumin is seen. 

Salicyl sulphonic acid test. 

This test is useful if only a small quantity of urine is available. 

To I in. of clear urine in a test tube add a few drops of a saturated solu- 
tion of salicyl sulphonic acid. If protein is present the liquid in the tube 
will appear turbid in comparison with the control tube containing the 
original urine. 

The .quantity of albumin may be ascertained by Esbach’s albumino- 
meter. This is a graduated corked test tube. Filter the urine if not already 
clear, and if alkaline render slightly acid with dilute nitric acid. If the 
specific gravity be i,oio or more, dilute the urine sufficiently to reduce the 
specific gravity to below that level. Fill the tube with urine up to the mark 
'Ub Add the reagent (Esbach’s solution of picric acid and citric acid) up 
to the mark ‘R’. The tube is then gently inverted a few times to allow the 
fluids to mix, and kept standing upright for 24 hours. The albumin is 
deposited and is read off on the graduated marks, which represent 
grammes of dried albumin per litre of urine. The percentage of albumin 
is obtained by dividing by 10. Allowance must be made if the urine has 
been diluted before the estimation was undertaken. 

B. Tests for blood. 

Pour about i in, of urine into a test tube, boil and cool. Add ^ in. of 
glacial acetic acid and mix. Add i in. of ether and invert several times. 
Into another test tube add ^ c.c. of alcoholic guaiac solution and 2-3 c.c. 
of ozonic ether. Pipette the ethereal extract from the first tube into the 
tube containing the guaiac and ozonic ether. If blood is present a blue 
colour will develop. 

-If the ethereal extract in the first tube does not separate ^ add a few drops 
of water to the contents without shaking. This usually brings about the separation of 
the ether. 

C. Tests for bile. 

1. Bile piginents. 

Fill a test tube J full of urine. Shake vigorously. If the urine contains bile 
the froth will be coloured yellow. 

Bile in the urine always colours the urine suggestively when in any quan- 
tity. Let fall a few drops from a pipette on a white tile and beside them a 
few drops of strong nitric acid; allow them to run together; where the two 
fluids mix, a passing play of colours, of which one must be green, will appear 
if bile be present. 

Iodine test for bile. 

Add 0*5 per cent, tincture of iodine drop by drop to the urine. In presence 
ol' bile pigments a dark green colour develops. 

2. Bile salts. 

Ilafs test. 

Place the urine in a glass beaker. Sprinkle some sublimed flowers of sul- 
phur on the surface of the urine. If bile acids are present, the sulphur sinks 
sooner or later in accordance with their percentage. 



62 OBSERVATIONS OF EXCRETA AND DISCHARGES 

D. Tests for sugar. 

Fehling^s test. 

If the urine be pale, increased in quantity, and of high specific gravity, 
sugar will be suspected. 

A small quantity of freshly made Fehling's solution is poured into a test 
tube and heated to boiling, and an equal quantity of urine added and 
heated — an orange red deposit proves the presence of sugar. Instead of 
Fehling’s solution, its component parts may be used separately — the liquor 
potassae and the urine boiled together and a few drops of sulphate of 
copper solution added — the result will be the same. 

The test fluid and the urine may be boiled in separate test tufics and 
allowed to flow together down the inclined tubes. 

Benedict's test. 

Place 5 c.c. of Benedict’s reagent in a test tube, and add 8 drops of urine* 
Boil over a flame for 2 minutes or place in boiling water for 5 minutes. 

Some idea of the amount of sugar present may be obtained by allowing 
the tube to stand for a few minutes. 

Greenish liquid without deposit, denotes 0*1 per cent. 

Slight yellow deposit with greenish liquid above, 0.2 per cent. An orange 
deposit with colourless liquid above it, indicates that the urine contains 
about 2 per cent, of sugar. 

E. Tests for acetone bodies. 

1. Aceto-acetic acid syn. diacetic acid. 

Ferric chloride test. 

Add a few drops of 10 per cent, ferric chloride to i in. of urine in a test 
tube. At first a precipitate of ferric phosphate appears. Continue to add 
ferric chloride and the phosphate will dissolve and a port wine colour is 
given if diacctic acid is present. 

N,B , — The test must be performed on freshly passed urine y because if the urifie is 
allowed to stand the diacclic acid becomes oxidized to acetone which does not give the 
test, 

A positive ferric chloride test shows that a very severe degree of ketosis 
is present. 

Rothera's test. 

Into a test tube put i in. of urine. To it add about i in. of ammonium 
sulphate crystals and shake. Add 2 drops of freshly prepared weak sodium 
nitro-prusside and about i inch of concentrated ammonia. A perman- 
ganate colour develops in presence of diacetic acid. 

2. Acetone, 

Rothera's test, (See above.) 

6. Examine Deposit. The deposit may consist of: 

Urates. 

Phosphates. 

Uric Acid. 

Mucus. 

Red blood cells. 

Pus cells. 



EXAMINATION OF URINE 63 

Urates disappear on heating the urine. 

Phosphates may be dissolved by the addition of acetic acid. 

Uric acid crystals. These resemble cayenne pepper grains lying at the bot- 
tom of the specimen glass. They have a characteristic appearance under 
the microscope. 

Mucus, This appears as a flocculent cloud in most urines and can be seen 
on the surface oi the urine if the specific gravity is high, or at the foot of the 
column of urine if the specific gravity is low. This is the only satisfactory 
test for mucus and its presence is of no significance. 

Red blood cells. If present in large amount they can be lecognized as a red 
deposit Colouring the supernatant fluid reddish brown or yellow. 

Pus cells. Pipette about 1 in. of the deposit from the foot of the specimen 
glass and transfer to a clean test tube. Add i in. of strong liquor potassae 
and stir. If pus is present in large amounts a gelatinous ropy mixture re- 
sults. (Blood cells and pus cells can be identified under the microscope.) 


STOOLS 

The normal stool varies in health, according as the individual is an 
infant, child or adult, and to some extent with the diet. A fluid diet pro- 
duces soft stools, a dry diet gives a hard stool. A heavy protein diet will 
make a stool offensive and dry, a milk diet will render it dry and crumbly 
and pale in colour. Certain vegetal^les may alter the colour, spinach pro- 
ducing a greenish stool and carrots a reddish colour. Certain drugs taken 
may produce some effect; astringents, such as tannic acid contained in tea 
will decrease the quantity, iron and bismuth will render the stool greyish 
black; laxatives and purgatives are intended to increase the quantity and 
the fluidity. 

The characteristics of a normal stool are: 

Frequency — one or two a day. 

Quantity — in the adult about four ounces. 

Consistency-soft solid. 

Colour— light brown. 

Odour — characteristic but inoffensive. 

Variations in disease. The quantity is increased in intestinal catarrh, 
diarrhoea, and whenever peristalsis is stimulated. It is decreased peris- 
talsis is sluggish, as in constipation, and in conditions in which fluid is 
being lost, as in sweating, vomiting and excessive bleeding. 

The consistency is always in relation to the quantity: increased quantity 
produces fluidity, decreased quantity renders the stool hard and solid, as 
water has been excessively absorbed. Very hard stools are described as scy- 
bala. Gritty particles occur when faecal collections have formed as in diver- 
ticulitis. The term ‘sheep droppings* is used to describe little hard round 
knobbly bits of faeces which have probably been passed through a spastic 
colon. Ribbonlike stools arc those which have been passed through a con- 
stricted colon, which may be due to spastic constipation or may indicate 
the presence of a sclerotic growth. A soft solid stool may sometimes be 
grooved as it is pressed past a prominence in the wall of the rectum and 
usually indicates the presence of an abscess in this region. 

Ricewakr stools arc a special type of fluid stool which has a turbid appear- 
ance with little flecks of mucus in it, characteristic of cholera. 



64 OBSERVATIONS OF EXCRETA AND DISCHARGES 

The odour of the stool is very little changed; sour-smelling stools occur in 
digestive disorders, and the stools are offensive whenever there is excessive 
decomposition, tissue destruction as in ulcerative enteritis and typhoid 
fever, and when the bile is absent as in jaundice. 

The colour varies rather more considerably. Bile, which normally colours 
the stool brown, is absent in jaundice, and so the stools are clay or putty 
coloured; and it might be noted here that the absence of bile retards peris- 
talsis — thus causing dryness of stool — gives rise to defective digestion of fats 
so that fat globules may be seen in the stool, and that these stools are also 
offensive and are the characteristic stools of jaundice. 

Green stools suggest digestive disorder and may also be produced by the 
administration of calomel. 

Blood alters the colour of the stool in several ways. The presence of al- 
tered blood (melaena) gives a tarry stool. When blood coming from the 
lower part of the small intestine is well mixed with the stool, but not ser- 
iously altered by the digestive juices, the colour is chocolate. Bright red 
blood indicates bleeding from the large intestine or very rapid bleeding 
from the lower part of the small intestine. In these two instances clot may 
be present. 

The more common abnormal constituents which are occasionally present are : 

Blood as just described. 

Mucus^ which may be in flakes or shreds, or as epithelial casts. 

Pus. 

Sloughs^ usually indicating separation of ulcers, as in typhoid fever. 

Gallstones — little grey particles, usually searched for after an attack of 
biliary colic. 

Undigested food — fat as globules; curds, from undigested milk; and sub- 
stances as fruit stones, skins, fish bones, &c. 

Intestinal Worms. 

The stools of an infant. During the early days, meconium is passed, 
which is a dark green fluid; during the first two months of life, the stools 
are like beaten-up egg in colour and consistency, slightly sour and number- 
ing three to four a day. They then gradually become slightly feculent, and 
at the age of about six months have become of the consistency of porridge 
and slightly brown in colour. 


SPUTUM 

Sputum or expectoration is usually coughed up from the lungs, though 
in many instances it contains a lot of saliva. 

Observations. It is important that a nurse should observe the 
amount of sputum, its colour, odour, tenacity — that is, whether or not it is cling- 
ing to the patient’s lips, and difficult to spit up. It is important to note the 
time when most of the expectoration is brought up, whether it is early 
morning, after a meal or after exertion. 

Character. Sputum is described according to its character. It may be 
abundant or scanty, clear or opaque; if opaque it may be mucoid, muco^pundent, 
purulent, albuminoid, bloodstained or rusty. It may also be frothy, deposited in 
layers or nummular; it may resemble pruru juice in colour in gangrene and ab- 



SPUTUM 65 

scess of the lung, egg yolk in jaundice, and anchovy sauce in pulmonary 
abscess complicating dysentery. 

Certain diseases have very characteristic sputa. In pneumonia it begins 
by being mucoid, then becomes tenacious and rusty, and later, when the 
condition is clearing up, it is frequently abundant, mucoid and frothy. 

In bronchiectasis^ the sputum is fetid, having a deposit of pus, a layer of 
brown fluid on top of this surmounted by froth. 

In pulmonary tuberculosis the sputum is described as glairy^ when it looks 
like sago grains. It is nummular^ which means that it comes up in coin- 
shaped masses lying on the bottom of rhe vessel into which it is expec- 
torated. This occurs when cavities are present. When the disease is ad- 
vanced, and there is a good deal of destruction of lung tissue, the sputum 
is greenish-grey and purulent. 

In asthma^ the sputum is scanty, frequently brought up in pellet-shaped 
masses, described as Laemec's pearls. 

Collection of sputum. The ordinary sputum cup has a little antiseptic 
placed at the bottom for the sputum to fall on unless a specimen is re- 
quired; here again when specimens arc needed a sterile flask is invariably 
provided (see fig. 26, p. 15 1). Patients who are walking cases carry a 
pocket sputum flashy made of blue glass with a screw top; and this, in order 
to avoid soiling the pocket, should be provided with a separate removable 
calico pocket. Patients with less copious sputum might be able to manage 
with handkerchiefs, but in this case paper handkerchiefs should be supplied 
and the nurse in charge should be careful to see that before the patient 
receives a clean handkerchief he should account for his soiled one which 
should be burnt. 

Disposal of sputum. Non-infcctious sputum may be emptied down 
the sluice or lavatory' pan, care being taken to avoid soiling the sides of 
the basin. Infectious sputum and sputum from all tuberculous persons should 
either be rendered innocuous before it is disposed of by boiling or 
disinfection, or it should be disposed of by burning. 


VOMIT 

The causes of vomiting are numerous y but there are certain observations a nurse 
will be called upon to make with regard to the manner in which the vomit is expelled 
and also regarding the character of the matter vomited. In most cases the contents 
of the stomach are first brought up — food, then gastric juice and later 
bile-stained fluid. 

Food is vomited in gastric and intestinal disorders. In biliousness subse- 
quent vomit b green because it contains a good deal of bile. In conditions 
of dilatation of the stomach vomit is usually at first copious, frothy and offen- 
sive, and is later followed by copious quantities of fluid which are bile- 
stained. In intestinal obstruction the vomit becomes feculent in odour. 

Bloody when vomited, is usually of the colour and consistency of coffee 
groundsy and acid in reaction; but if it is regurgitated from the duodenum 
it may be alkaline, and if bleeding is taking place very rapidly it may be 
bright red because it is unaltered by digestive juices. 

Anaesthetic vomit is usually yellowish-green and smells of the anaesthetic.^ 

When corrosive acids or alkalis have been swallowed, as in cases of 
poisoning, the vomit contains altered blood and frequently casts of the 



66 OBSERVATIONS OF EXCRETA AND DISCHARGES 

oesophagus and stomach. The vomit is phosphorescent when phosphorus 
has been taken. 

As a rule vomiting implies considerable effort, and is associated with 
nausea, except in the following instances: in intestinal obstruction it is 
regurgitant in character, flowing out of the mouth without effort; in pyloric 
stenosis it is described as projectile since the stomach contents arc forcibly 
ejected; cerebral vomiting is unassociated with the intake of food — it may 
be projectile in character. 

Nursing care. The act of vomiting reflexly stimulates the vagus nerve, 
and so causes the patient to feel faint and dizzy, and also temporarily 
lowers the blood pressure and depresses the heat regulating centre. More- 
over, it is a very unpleasant symptom, and the patient needs sympathy and 
tactful nursing attention. The nurse herself may be nauseated as she stands 
by a patient who vomits, but she must not show this by look or gesture. 

During the act of vomiting she should protect the bedclothes, remove 
the patient’s false teeth, hold the basin for him and support his head by 
placing her hand over his forehead. She should consider whether the 
patient has any abdominal wound which might be strained and get the 
patient to support it during the act, since she herself already has her hands 
full. After the attack she should rinse the patient’s mouth out, clean it if 
necessary, clean his dentures and replace them, note the patient’s general 
condition, the amount of distress and prostration caused, wipe the cold 
clammy perspiration from his skin, wrap him in a hot blanket, give him a 
hot water bottle and, unless contraindicated, give some hot water con- 
taining saline or glucose or sodium bicarbonate to sip, disguising the 
flavour with a little lemon juice if necessary. The nurse must remember 
that vomiting is one of the sources of dehydration, as it not only removes 
fluid by the act but also lowers the blood pressure, consequently diminish- 
ing the amount of fluid circulating in the tissues of the body. 

Vomiting in infants may be due to an acute or a chronic condition, 
or it may occur as the result of some deformity or malformation, most 
commonly that associated with pyloric stenosis. 

Acute forms of vomiting occur in acute gastro-intestinal disease as in 
epidemic diarrhoea and vomiting; and at the onset of acute febrile or in- 
fectious diseases such as meningitis. The vomiting which characterizes 
congenital pyloric stenosis in severe cases may also be considered to be 
acute. 

Less acute, or more chronic vomiting is usually due to errors of feeding, 
which include the swallowing of air, too rapid feeding, during which the 
infant is not given the rests necessary for liim to bring air up, and jumping 
or jerking the infant about cither before or after feeding. TTic use of un- 
suitable foods containing either too much sugar or fat or forming too heavy 
a curd may also be the cause of vomiting. A little unaltered food brought 
up during or soon after a feeding is described as posseting. 

Nursing care. It is important that the nurse in charge of an infant who 
may be vomiting should consider whether the cause be attributable to the 
food given or to the manner of giving it, and she should take steps to cor- 
rect what may be wrong. 

In making a report on the vomit she should be careful to state whether 
it contains curds, and of what type these arc; and also to note the presence 
of blood, bile or mucus. 



VOMlf 67 

The type of vomiting should be noted, whether projecHU as in menin- 
gitis, or effortless as in serious cases of vonuting and diarrhoea, when the 
vomit dribbles out of the mouth and runs down over the chin. 

Ruminating vomiting is a type which occurs in healthy infants; the baby 
or toddler is seen to make a succession of movements of his jaws and tongue 
and begin mastication; he gulps and brings fluid, or solid food, in the case 
of a toddler, into his mouth. It is thought that the cause is a psychological 
factor, and probably the infant wishes to create a disturbance and receive 
notice. The treatment is to break the habit by giving thickened feedings, in 
the case of a tiny baby; and limiting the intake of fluid, particularly not to 
give water between meals, in the case of an older infant. 

The time factor is important in relation to the intake of food, and the 
nurse should note whether the infant vomits before or after feedings or in 
between them. 


VAGINAL DISCHARGES 

A nurse should never imagine that a vaginal discharge is normal. The 
vagina certainly is moist, but garments should never be stained by its 
secretions. 

Leucorrhoea^ which is a white yellowish opaque discharge, is probably the 
one most commonly seen, and it indicates excessive secretion of the cervical 
glands and is frequently met with in young women. It is comparatively un- 
important, and will usually be found to improve when the standard of 
general health is raised. 

Any inflammatory condition of the genital tract may pixxluce a dis- 
charge of mucuSy a mixture of muois and pus^ or pus. In gonorrhoea the dis- 
charge is deiinitely purulent. 

An offensive vaginal discharge may be due to a streptococcal infection or to 
gonorrhoea. The discharge is always oflTensivc in cases of senile vaginitis 
and endometritis. 

In ulcerative conditions of the cervix and uterus such as occur in the late 
stages of carcinoma, the discharge is bloodstained and offensive. 

Nursing care. The toilet of the vulva should be frequently attended 
to in order to prevent excoriation of the surrounding skin by vaginal dis- 
charge. Sterile pads should, if possible, be used. 

The quantity, colour, odour and general character of the discharge 
should be noted. In removing the pad, place the palmar aspect of tlie hand 
over it, and double and fold it gently on to itself, at the same time wiping 
in a direction from before backwards; then place it flat on a receiver 
brought to the bedside for this purpose, covered with a second receiver 
while carrying it. If the pad is to be kept for the doctor's inspection it may 
remain in these vessels, but otherwise it should be wrapped in paper and 
placed in the sanitary bin which will eventually be emptied by the hos- 
pital porter. In a private house it might be possible to burn it immediately. 

COLLECTION OF SPECIMENS 

A nurse will be called upon to collect s^cimens of the excretions and 
more rarely of the secretions of the body from time to time. Most com- 
nmaly specimens of urine, faeces, sputum and vomit will be required* 



68 OBSERVATIONS OF EXCRETA AND DISCHARGES 

The examination of such specimens will be necessary for a variety of 
reasons, particularly in order to arrive at a diagnosisy to note the progress 
of the disease, to observe the effect of any special treatment or drug, and, 
in case of specimens of urine, before the administration of a general anaes- 
tiietic* 

Urine. An ordinary specimen — that is, the routine specimen collected 
either on admission or daily, or twice weekly, in the routine administra- 
tion of a ward — may be taken first thing in the morning after the patient 
has had a night’s sleep, or last thing at night after the patient has sustained 
the rigours of the day. 

To collect this, the nurse gives the patient a clean bedpan or urinal, and 
saves 5 ounces of the quantity passed in a clean specimen glass, which 
should then be covered and labelled with the name of the patient, the 
ward, and the date on which it was collected. In collecting such a specimen 
from a female patient warn her that it is required and ask her not to have 
her bowels moved at the same time if she can avoid this; should she be 
menstiTiating the nurse should swab the vulva and place a pad of absor- 
bent wool into the vaginal orifice over which tlie urine trickles into the 
bedpan and, with care, mixing of the menstrual flow can be avoided. In 
this case, however, it is as well to make a note that the woman from whom 
the specimen was obtained is menstruating. 

A sterile specimen can only be obtained by means of catheterization and 
should then be put up in a sterile specimen glass or flask and the word 
‘sterile’ added to the label. 

When a 2^-hours" specimen is necessary it is important to ensure that it is 
collected from the whole 24 hours, neither less nor more. The nurse accord- 
ingly gives the patient a vessel, notes the time, writes it down on a label, 
puts this label on a large clean bottle, usually a winchester holding 4 or 5 
pints, and throw^s that urine away. She then puts all urine collected until 
the same time next day into that bottle and, for checking purposes, should 
write on the label the amount obtained, and the time it was passed, each 
time she adds urine to the bottle. She must inquire whether the whole of 
the urine collected is to be sent to the laboratory, or whether only a speci- 
men of it is needed — in the latter case she should mix the urine by inverting 
the bottle several times, then pour out 5 ounces, cover and label as before 
described, adding to the label the fact that a specimen had been taken 
from a 24-hours’ collection of urine. 

To collect a specimen from a baby. In the case of a girl, use a sterile napkin, 
place a pad of wool in front and below the vulva, and when the baby has 
passed urine the nurse places this wool in a sterile wringer by means of 
forceps and squeezes the urine into a clean glass. If the infant is a boy the 
penis may be placed in a sterile test tube provided the sharp edges of the 
top are covered by stretching a piece of rubber from the finger of an old 
surgical glove over it, or by means of wool. 

In cither case it may be possible to obtain a specimen by ‘holding the 
infant out’ over a clean vessel. 

Faeces. A sterile specimen glass should be labelled, and the specimen 
sent to the laboratory as soon as possible after it is passed, the hour it was 
obtained being added to the information on the label. The specimen should 
not contain any disinfectant. When collecting it, choose the soft solid por- 
tion of the stool, removing this from the bedpan by means of a sterile 



COLLECTION OP SPECIMENS 69 

spatula or scoop specially provided for the purpose; add to the specimen 
anything that loolu abnormal in the stool and take great care not to con- 
taminate the outside of the glass. See that it is securely corked. 

Wrap the glass in a piece of clean white paper, or enclose it in an en- 
velope, marked ‘faecal specimen’. 

If a specimen of faeces is to be examined for the presence of amoeba, 
the whole stool should be poured into a receptacle warmed by placing it 
in water at a temperature of lOO® F. and sent to the laboratory while still 
warm from the patient’s body. 

When a specimen of faeces is needed for examination to detect the pres- 
ence of occult blood it is important for the nurse to see that the diet has not 
included red meat during the previous 48 hours. She should also warn the 
patient to try and avoid injuring his gums when cleaning his teeth, and 
she should also ask him to let her know if by any chance he swallows a 
little blood from the back of his nose, mouth or throat, as this would render 
the test useless. 

Any abnormal stool should be saved intact for inspection at the doctor’s 
next visit, either in the vessel in which it is received or in a shallow bowl. 
It should be covered and placed in an air cupboard if one is available. 

Sputum. In collecting a specimen of sputum it is best to get this first 
thing in the morning, before the patient has had his breakfast. He should 
be told that such a specimen will be required. A small corked specimen 
glass, ready labelled, is provided standing on a receiver at his bedside, and 
he is told that he is to expectorate the secretion that comes up from his 
lungs into this without moving it about in his mouth or collecting a lot 
of saliva. It is important that saliva should not form the bulk of the speci- 
men so collected. 

The patient should also take care not to soil the edges or the outside of 
the specimen glass. It was previously labelled so that the nurse need not 
handle it after the specimen has been added, unless in the case of a helpless 
patient she should be obliged to hold the specimen glass for him whilst he 
expectorates. It should be carried to the laboratory on a tray and not in 
the hand. 

Vomit. As a general rule vomit is kept in the bowl in which it is re- 
ceived, which should be covered as it is moved about the ward or conveyed 
to a laboratory for examination. 

[See also receptacles for the collection of specimens, fig. 26, p. 151,] 

A nurse may be expected to provide for the accommodation of a speci- 
men of blood, cciebrospinal fluid, fluid from one of the serous cavities 
such as may be obtained on aspiration of the chest or pericardial sac, or 
of the peritoneum, or specimens from any of the body cavities such as the 
nose, conjunctival sac, throat or vagina, or the pus or other contents from 
any wound or abscess. 

Specimens of cerebrospinal fluid, or fluid from the serous cavities are usually 
collected in sterile test tubes. When handling the tube the nurse must be 
careful to sec that it is not contaminated, and that the rubber bung or 
cork which is also sterile is replaced as quickly as possible, without touch- 
ing the sides of the glass. 

The label conveying the necessary information should immediately be 
attached to the specimen. 



•JO OBSERVATIONS OF EXCRETA AND DISCHARGES 

Pus or fluid from wounds and abscesses may be collected in the same 
way. 

A specimen of the secretion from the eye or other mucus-lined cavity is usually 
taken by means of a sterile swab. This consists of a fine piece of wire or a 
thin stick with a wisp of absorbent cotton wool wound on to one end; this 
is placed in a test tube, the free end of the wire being attached to the cork 
or rubber bung which fits the tube, all of which have been sterilized. The 
specimen is obtained by gently touching the part affected, so that secretion 
is received on to the cotton wool; the swab is then immediately replaced in 
the test tube, putting it in carefully so as to avoid touching the sides of the 
tube as the swab is replaced. The tube is labelled as necessary and put 
aside for examination. 

Specimens of blood. A nurse will frequently be asked to prepare for 
the collection of blood for examination, but only rarely will she be expected 
to collect this. 

When a large quantity is required it is obtained from a vein. The apparatus 
required is: 

A spirit lamp and sterile test tubes or culture tubes. 

Forceps to handle the different parts of the apparatus when fitting it to- 
gether. 

Antiseptic and swabs to cleanse the skin. 

A tourniquet to compress the vein, so that it will stand out prominently 
and mzike it easy to insert the needle. This tourniquet may be a piece of 
rubber tubing, stretched and placed round the arm and held by a pair 
of Spencer-Wells’s artery forceps. Or an inflatable tourniquet may be used, 
such as that employed with the sphygmomanometer. In some cases the 
nurse, being adept, compresses the vein by manual pressure. 

A sterile syringe and needle, of 5 c.c. or 10 c.c, capacity; this may be stand- 
ing in sterile water or sterile paraffin. 



Fio. 10. 

(A) Wright’* capsule. (B) Graduated pipette. 

A nurse should realize that the needle and syringe used for the collection 
of blood for examination must be absolutely sterile. It may be boiled for 
20 minutes or, alternatively, some physicians prefer to have syringes and 
needles sterilized in liquid paraffin, as in this way they do not so readily 
become contaminated; moreover, the paraffin, acting as a smooth covering, 
prevents the blood from clotting. This may not always be a practical pro- 



COLLECTION OF SPECIMENS 7 1 

position for the ward sister, but many of them do find it possible to sterilize 
needles in liquid paraffin, in a little tin bath over the bunsen burner in 
their test rooms, and needles kept in this solution do not so easily get rusty 
as when stored in spirit. 

A small quantity of blood is usually collected either by means of a Wright’s 
capsule, by a graduated pipette or on a glass slide, and a nurse may be 
expected to do this. 

Wright's capsule (see illustration). The skin is cleansed with a little anti- 
septic or ether, and jabbed or pricked with a Hagedorn needle, the point 
of which is sterilized by holding it in the flame of a spirit lamp. After it 
has cooled blood is drawn, the bent end of the tube is placed in the drop 
of blood and it passes along up the tube by capillary attraction. When it is 
three-quarters full remove the tube, gently heat the top part to get the air 
out, and then seal both ends by heating them in a flame. 

Several capillary tubes should be supplied, as sometimes the blood clots 
just as it enters the tube and then it does not fill. This specimen would be 
discarded and another attempt mtide. 

Glass slide. Blood is obtained in the same way; a drop is received on to a 
clean slide, and this is smeared to render a thin film of blood available by 
taking a second slide and wiping it along the first. 

A graduated pipette is provided when estimating the amount of haemoglobin 
in the blood. The skin is cleansed and dried and a fixed amount of blood 
is drawn into the pipette. Some means is then employed to liberate the 
haemoglobin by breaking down the red corpuscles and so liberated the 
amount can be determined. 

SEDIMENTATION RATE 

The rate at which the red blood cells sink in plasma is increased in cases 
of tissue breakdown due to infection and toxaemia. The fewer cells present 
in blood the lower is the surface tension and coasequcntly the sedimenta- 
tion rate is greater. 

Estimation of the sedimentation rate is valuable only as an indication of the 
progress a patient is making, it is looked upon as a gauge of prognosis and 
is not used as an aid to diagnosis. The rate is increased in pleural effusion, 
tuberculosis, in practically all true febrile conditions and in rheumatism. 
By observation of the sedimentation rate at weekly intervals improvement 
can be noted. 

A number of methods are employed for making this investigation; when 
Westergren’s method is used four cubic centimetres of blood are added to 
one cubic centimetre of a solution of 3-8 per cent, sodium citrate and 
placed in a vertical glass tube. This tube is graduated from o to 200, after 
one hour a reading is t^n and the figure on the tube to which the blood cells 
have sunk in the plasma is noted. As the tube is graduated to 200, this 
figure is divided by two in order to obtain the percentage. In normal per- 
sons the sedimentation rate is from i per cent, to 10 per cent. In patho- 
logical conditions it may be high, e.g. from 30 to 50 per cent. 



Chapter 5 

The Care of Materials and Appliances Used 
in Making Beds 

Hospitd beds and bedding — Removing stains from materials — Care of rubber 
gooh — Making beds: moving patients in bed : Special types of beds — The use of 
bedblockSy cradles, rests and tables, air and water beds and pillows 

THE MATERIALS USED FOR HOSPITAL BEDS AND BEDDING 

F or general purposes the ordinary hospital bed is 26 in. high, 
6 ft. 6 in. long and 3 ft. wide. The framework is of enamelled steel or 
iron, the castors are well made, and so move easily without jarring. 
The spring mattress is of stout wire, easily cleaned. There arc many modi- 
fications of this bed, some have a movable back, and this is convenient as 
it can be moved forward to act as a bedrest or removed when required for 
washing and dressing the head. Other bedsteads are so planned that by 
means of levers the top or bottom of the bed can be lowered or raised; an- 
other bed is so modified that it can be made to support the patient in Fow- 
ler’s position, and various other modifications are also supplied by different 
makers. 

The mattresses used are made of horsehair, as this material is non- 
absorbent and durable, and withstands constant exposure to heat — as in 
steam disinfection — better than other materials. From time to time as the 
mattresses lose shape and get thin the horsehair can be washed and picked 
and new mattresses made up by the addition of some fresh hair. Mattresses 
are covered by strong bed ticking which lasts a considerable time in spite 
of frequent brushing and handling. Leather tags should not be used, as 
these p>erish when heated. 

Care, It is important to protect mattresses from becoming wet and 
stained, and this is best done by the use of long mackintoshes. They should 
be brushed at regular frequent intervals to prevent collection of dust in the 
seams and under the buttons if these arc used for the mattressing. As far as 
possible cotton mattress covers which fit and completely cover the mat- 
tresses should be used, and these can be changed every two weeks when in 
use and also on the discharge of a patient. 

To prevent the rusting of the mattress from the wires of the spring, stout 
covers of sacking or canvas are used; these are tied on to the bedstead by 
tapes, top and bottom and each side, in order to prevent their slipping or 
rucking under the mattress. 

Pillows are filled with a variety of materials, as some pillows must be 
firm, while those under the head should be soft and comfortable. Ticks 
which are impervious to dust are used, and over these a cotton cover is 
stitched which can be removed for washing. In this way the pillow tick, 
which is expensive, is kept clean, while the cotton cover which is frequently 
changed looks clean also. 


7 « 



MATERIALS USED FOR HOSPITAL BEDS 73 

Pillows require impecting from time to time, as they may get lumpy or 
thin, and may then require renewing. They should be protected from be- 
coming wet or stained and, when pillows are used in circumstances where 
such protection is impossible, then mackintosh covers should be provided; 
these may be loose, tied with tapes or buttoned, but it is better for the 
covers to be stitched on so that the pillow is thoroughly protected. 

Pillowcases may be of linen or cotton material; they should be sufficiently 
large to fit the pillow loosely, otherwise a comfortable soft pillow com- 
pressed by the case it is in will be made hard and uncomfortable. The fas- 
tenings supplied, whether tapes, buttons or envelope flaps, should be kept 
in go^ condition. 

Blankets should be light in weight and large enough to tuck in at the 
bottom and sides and come well up on to the patient's shoulders. They 
should not be used doubled, as this only adds to the weight without giving 
warmth. These are expensive articles, and they do not readily stand fre- 
quent washing or steam disinfection without shrinkage. Blankets should be 
protected by the quilt, and by turning the sheet well over at the top, and 
they should never be exposed to dust. When a blanket is to be used under 
or next to the patient thin old ones should be used or non-inflammable 
blankets of flannelette may be specially provided for this purpose. Thin 
old blankets should also be provided for blanket bathing. 

When in store, blankets should be carefully protected from moth, and 
should be covered by dust sheets. 

Linen. Sheets, drawsheets and pillowcases may be made of linen or 
cotton material. Sheets must be long and wide for the type of bedstead des- 
cribed. Stains should be removed from all linen materials as soon as pos- 
sible, but bleaching substances should not be used for this as they tend to 
weaken and rot the material. 

Care of linen. Linen must be inspected as it is put away on return from 
the laundry, all pieces showing tears or thin places being put aside for 
mending; no torn linen should ever be used on a bed or allowed to remain 
in use for a moment once it is torn, as the injury will become greater if it is 
\ised, and this would constitute a serious extiavagance as linen is an expen- 
sive item of hospital expenditure. 

Condemned linen. Most ward sisters have a book in which they make a list 
of the linen they consider unfit for further use, and this linen is in due 
course inspected by one of the administrative sisters, who endorses the book 
and issues new linen to replace the old. In this way the stock is kept up, 
and a check is also kept on the length of time linen is usable (and used), 
the way in which it wears, and the cost it is to the hospital. Probationers 
should remember this, especially when they are tempted to use some badly 
torn article as cleaning rags. 

Old linen. The linen room staff which decides upon the condemnation of 
old worn linen, and the issue of new, whilst using ever^^ old piece possible 
for patching other articles, will still have for disposal much that is too thin 
and worn for any further use, and this should be available whenever old 
linen is needed, as in dressing skin cases; old pieces of blanket arc available 
too, and can be utilized for medical fomentations and stupes, etc. 

Drawsheets arc supplied in a slightly warmer and more readily 
absorbent material than the ordinary bed sheets, and they may be cither 
single or double. They arc called ‘drawsheets* because they arc long 



74 the care of materials 

enough to be drawn through from one side of the bed to the other so that 
the patient may from time to time be given a cool part to lie on. In no 
circumstances whatever should a damp or soiled drawsheet be drawn 
through, as if this were done the dirty part would be left tucked under one 
side of fhe mattress, which would be unhygienic, while in addition the 
soiled sheet would probably cause the mattress to be soiled as moisture 
soaked through it. 

Drawsheets are sometimes soiled by excreta, and when this happens 
they should be soaked in cold water containing some disinfectant, then 
well scrubbed with a brush and finally, when the stain has been removed as 
much as possible, sent to the laundiy, specially marked ‘wet and stained 
linen’. 

A drawsheet should never be hemmed, patched or darned, because the 
patient’s buttocks lie heavily on it and any unevenness or lumpiness of the 
surface wall predispose to bedsoreness. 

Mackintoshes. Long mackintoshes arc used to cover the mattress, and 
they should tuck in at the top and bottom of the bed. Short mackintoshes 
are used under the drawsheet, and these, so that they may be completely 
covered by the drawsheet, should not be quite as wide as the latter, but 
in order to keep them taut they must be long enough to tuck in on each 
side under the mattress. 

Mackintoshes are best if ‘proofed’ both sides. 

Quilts. Cotton quilts are used as they arc easily washed. 


REMOVING STAINS FROM MATERIALS 

The materials most commonly stained in hospitals are bed linen and 
bedding and personal linen. For the removal of such a stain some solvent 
is used which will either dissolve or remove the substance. 

Bloodstains and stains from some forms of excreta contain proteins 
which are coagulated by the application of heat; so for all stains of this 
nature, including milk stains, the article should be soaked in cold water 
for some time and then w^ashed in tepid or hot water. If the staining 
element contains a good deal of fat, hot water and soap should be used. 

When an oily or fatty substance has contaminated an article of clothing, 
some alkali should be added to the hot water such as soda, soap powder, 
borax or ammonia. Greasy marks can be removed by petrol, benzine or 
ether, but these substances are highly inflammable. 

Any stains of medicine may be treated by water or methylated spirit 
as many drugs are soluble in spirit and many more in plain water. 

Iodine stains and most of the aniline dyes can be washed out if treated 
immediately. Stale iodine stains may respond to carbolic lotion 1-20. 

Stains of paint or varnish can usually be removed with turpentine or 
alcohol. 

Stains of tea, coffee, and fruit will usually be removed by soaking the 
material in water, or more quickly by stretching the stained part over a 
basin and pouring boiling water on to it; if borax can be obtained, this 
should be applied first and the boiling water poured over it. 

If the stains do not respond to this treatment, lemon juice rubbed in 
may do it, or a little peroxide of hydrogen, but the latter is a bleaching 
agent and tends to destroy materials. Bleaching in the sun is better. 



REMOVING STAINS FROM MATERIALS 75 

Inkstains in linen respond most quickly to soaking in milk, or lemon 
juice may be tried, washing in water and bleaching in the sun. 

Stains from scorching can often be removed by bleaching in the sun 
slight stains will wash out. If the scorch is noticed as soon as made, rubbing 
the surface over with a penny is very effective. 

The application of some absorptive substance such as salt, starch or 
borax will prevent any liquid from spreading and thus reduce the ultimate 
damage to the material. 

Bleaching agents are frequently used in rendering linen white, but they 
require care in use as most of them are destructive to linen. 


CARE OF RUBBER GOODS 

Rubber goods in use should not be creased or folded, and they 
should be protected from friction and injury— -pins for example must not 
be put through them, neither should they come into contact with hot water 
bottles, and metal l)o:tles particularly tend to injure mackintoshes. 

Mackintosh articles should always be covered by a cotton or linen cover 
and never in any circumstances should two rubber surfaces be permitted 
to lie together. Any fluid spilt on them should be wiped off at once. Oil is 
very injurious. 

All mackintosh and rubber goods require to be washed regularly, and 
some definite order should be made, such as a weekly or at least fortnightly 
washing for goods in use. 

To clean mackintoshes. The best way to remove stains and to 
cleanse them without injury is as follows: 

(1) Soak the mackintoshes in cold water. 

(2) Rub each surface well over with soap jelly or soft soap, and then 
cither roll each mackintosh up separately or, better still if treating a num- 
ber, place them one on the other in a pile and allow them to stand, for say 
half an hour; though, if a large number are being treated, by the time the 
last is rubbed over with the soap the first, that is the lowest one of the pile, 
will be ready for rubbing and rinsing. 

(3) Spread each mackintosh on the board provided and rub it well over 
with tow or a soft cloth, treating both sides. 

(4) Then put the mackintosh to soak in warm water in the sink or 
mackintosh bath. Continue until all the mackintoshes are soaking in tlie 
warm water. 

(5) Now dry the board and place a cloth on it, and lifting each mackin- 
tosh out separately place it on this and dry with a cloth and then place it 
over the mackintosh roller to dry off completely. When all have been 
treated, they will be ready for return to the beds or for storage. 

Most hospitals are now provided with a specially wide sink, used as a 
mackintosh bath, and an equally wide board, usually grooved and ar- 
ranged on a slight incline towards the sink so that water easily runs off it. 
If this is not provided, it is convenient to use a board placed across a sink 
or bath for the purpose of cleaning mackintoshes. 

To store mackintosh goods. Seeing they are perfectly dry, powder 
lightly with french chalk and put away either flat or rolled — not folded — 
taking care to sec that two mackintosh surfaces do not lie together but are 
separated by special cloths, or old linen or paper. 



76 THE CARE OF MATERIALS 

Rubber beds and cushions and rubber hot water bottles may be cleaned in 
exactly the same way as mackintosh sheets, but it is advisable to inflate 
these very slightly as otherwise when rubbing them there is a tendency 
for the pressure of the hand to bring strain upon the seams at the sides 
of the articles, and in time they may crack or weaken here. 

The valves of beds and cushions should not be immersed in water as it 
spoils them and is one of the reasons why they easily get out of order. 

When storing these articles they should be slightly inflated, and the pre- 
cautions taken in the case of mackintosh sheets also used. Rubber goods 
should not be kept long in storage as they lose their elasticity and tend to 
harden and crack — those in store should therefore be changed with those 
in use once a fortnight. If it seems imperative to store some these should be 
taken out and treated by \vashing and rubbing, and stretched by hand 
every two or three weeks in order to help preserve the elasticity. 

BEDMAKING 

Certain principles have to be considered, and certain points remem- 
bered, in making beds: (a) in order that the patients’ comfort may be en- 
hanced, and (b) that due economy may be observed in the use of 
equipment. 

The locker or bedside table should be cleared and either one wide- 
backed chair, or two chairs faced back to back, should be arranged two 
or three feet distant from the bottom of the bed, on which the bedclothes 
can be neatly laid whilst the bed is being made, so that they will not drag 
along or touch the floor. 

AU articles likely to be reejuired should be collected such as the linen, a 
receptacle for soiled linen, a bedbrush or duster. If the bed is occupied it 
should be inspected to sec what clean linen may be necessary', and also as 
to whether clean bed attire is needed for the patient, and these should then 
be provided. 

For a helpless patient, two nurses would be required to make the bed; 
as far as possible one should take the lead and the other follow, so that 
they work together in harmony: their work should be quietly and quickly 
performed. The nurses should be opposite one another, at each side of the 
bed; needless journeys up and down the bedside should be avoided, the 
whole of the arm from the shoulder should be employed in the necessary 
movements, which should not be limited to the forearm as this is poor 
economy of energy and leads to clumsiness of movement. All patting of 
bedclothes and jarring of the bed should be most carefully avoided. The 
bedclothes, including the bottom sheet, should be untucked all round be- 
fore beginning to make or strip a bed. 

The articles required for making a bed include a canvas cover to 
protect the mattress from ironmould stains caused by contact with the 
wires of the bed. A cotton cover may be used to protect the mattress from 
dust; similar covers for pillows may be supplied, but in some cases cotton 
covers arc stitched on over the pillow tic^g. Ck>tton material costs much 
less than bed ticking, and the covers used can easily be removed for wash- 
ing when soiled. 

For^hospital patients a long bed mackintosh is provided under the sheet; 
itjprotccts the mattress from dampness or soiling and may or may not be 



BEDMAKINO 


77 

covered by a thin underblanket. Two sheets will be required; a short 
mackintosh and drawsheet; one or two blankets — or more, if liked; a day 
quilt, and a cotton cover for the night time, so that the blankets are not 
exposed to dust when the day quilt is removed. Several pillows and pillow- 
cases will be provided. 

Other articles that may be needed include: Air rings and water pillows 
to increase comfort for patients who arc thin, or who have to lie in any one 
position for a long time. A bedcradlc may be needed to keep the weight of 
the bedclothes off a painful part. Some form of heat may be needed, either 
hot water bottles, or an electric blanket or electric cradle. A bedrest may 
be needed when the patient has to sit up, a knee pillow when his knees are 
to be flexed, and a footrest if he is likely to slip down the bed. 

The bedclothes should be placed ready on one or two chairs by the bed- 
side; they should be arranged in the order in which they will be used; 
linen articles will be folded by the laundry and the folds will make creases; 
as everything ought to be put on the bed straight, the crease down the 
centre of a sheet may be used as a guide to straightness. 

The bottom bedclothes* long mackintosh and sheet should be taut; 
the latter should be tucked over the mattress at the top, then pulled taut 
and tucked in at the bottom of the bed, then across the middle where the 
patient’s buttocks will rest, then at the top and from side to side across 
the bottom part of the bed which is tightened last. This order of handling 
the bedclothes is also adhered to when making a bed with a patient 
in it. 

The short mackintosh and drawsheet are supplied to prevent soiling of 
the bottom sheet by excreta when sanitary utensils have to be used in bed; 
drawsheets arc from 2^ to 3 yards long, this is so that the sheet may be 
drawn through, from time to time. 

A patient’s face should never be covered by a sheet whilst making the 
bed. If the clothes are turned up, they should be folded under his chin and 
not placed over his face. The bedclothes should not be drawn tightly over 
the patient’s body, nor taut over his feet. They must be comfortable, and 
the patient should always be able to dorsiflex his feet quite easily and 
freely and move his legs up and down in bed, and turn over as he wishes. 

A patient must always be warned when movement is expected or is 
about to be carried out; if he is unable to help himself, or this is inad- 
visable, he should be properly helped and well supported during move- 
ment. 

Any part of the bed likely to be soiled should be specially protected by 
a mackintosh and drawsheet, or by a towel lined with jaconet. 

In making a bed with a patient in it, the method depends to a great 
extent on the condition of the patient. Figs. 27 and 28 on p. 152, 
show stages in the changing of a bottom sheet (a) when the patient may 
be rolled, and (b) when he must be lifted. Bedmaking is so essentially 
practical that detailed instructions of the various methods arc not in- 
cluded. 

LIFTING AND MOVING PATIENTS IN BED 

Certain principles have to be considered when about to move a patient 
in his bed: (i) It is essential to have a decided plan, which should be ex- 
plained to the assistant so that she may tlioroughly understand what is 



y8 THE CARE OF MATERIALS 

about to happen and that any jerky uncomfortable movements may be 
avoided. The one in charge should give the commands throughout. 

(2) The bedclothes should be rearranged so that their weight does not 
impede movement of the patient. In the majority of cases all top bed- 
clothes are removed as in the making of a bed, and the patient lies beneath 
one covering blanket. 

(3) The nurses should bend from the hips, keeping the back straight; in 
this way a great effort can be made with the minimum of discomfort. 

(4) The arms of the nurses handling the patient should pass fairly well 
round his body, and in lifting him from the bed should be passed well 
under the patient, and as far to tlie other side as possible, in order to give 
adequate support, 

(5) It is essential to have sufficient help. Nurses should never attempt to 
move a patient who is too heavy for them to lift, as this will give the 
patient great discomfort, probably mean that he loses confidence in his 
nurse and, in addition, cause undue and unnecessary strain on the nurse. 

SPECIAL TYPES OF BED 

Beds may be modified in different ways for the convenience of nursing a 
variety of cases. Some of the commonest modifications include: 

Operation bed* A bed for a patient who has had an anaesthetic (see 
fig. 29, p. 153). Certain points require consideration in the preparation of 
this bed: ( i) It should be wanned, and this may be carried out by the use 
of an electric cradle or an electric blanket or by means of hot water 
botdes; when the latter are used three should be employed, placed down 
the middle of the bed. In all cases the appliance used should be covered by 
the bedclothes, in order to keep the warm air in the bed. 

(2) One or two blankets should be provided in which to wrap th? 
patient. These should be warmed and this may be done cither by folding 
them over the hot water bottles or placing them beneath the electric cradle. 
The bedclothes that are to cover the patient should be conveniently 
arranged so that they can easily be removed when the patient is brought 
back to the ward. The usual order is maintained — i.c. top sheet, blanket 
and quilt. 

(3) The bottom of the bed should be protected by a long bed mackin- 
tosh as incontinence may occur while the patient is unconscious. In addi- 
tion, the part of the bed on which the affected part is to lie should be 
further protected by a small mackintosh and towel or drawsheet, placed 
to lie, for example, under an affected leg, a shoulder or head. 

(4) Any pillows for use in the vicinity of the wound are likely to be 
soiled and should be provided with mackintosh covers. 

(5) A fresh nightdress should be ready at the bed in case of necessity, 
and screens should be provided. A vomit bowl and towel should be plac^ 
at the bedside and swabs with which to wipe the patient's mouth* In cases 
in which an airway is not used it is advisable to have ready tongue forceps, 
mouth gag and sponge holders in addition. 

(6) Certain other appliances may be required. For example, bcdblocks 
or, as they are sometimes called, shock blocks, for elevation of the foot of 
the bed in case of shock or collapse. The articles for the administration of 
a rectal saline or blood transfusion should be at hand. In some ca«cs 
oxygen may be required and, in others, carbon dioxide may be necessary* 



SPECIAL TYPES OF BEDS 79 

Reception of the patient. When the patient is brought to the ward the nurse 
should see that there is a clear gangway from the ward door to the bedside. 
The upper bedclothes, hot water bottles, or electric cradle should be re- 
moved and the patient placed gently on the bed in the position in which 
he is to lie until he has recovered from the effects of the anaesthetic. In 
the majority of cases he will be placed on his back; if the abdomen has been 
the site of operation a pillow may be placed under his knees, and if he is at 
all restless the knees may be tied together by means of a soft flannel or 
domett e bandage. 

The head should be turned to one side in case the patient vomits, as 
there is danger of inhalation of the vomited material. The towel provided 
should be tucked round the patient’s neck, and under his chin, and spread 
out on to the bed and so arranged that the patient’s cheek rests on it; in 
this way the bedclothes would be saved should a little vomiting occur 
before the nurse can nach the bedside. 

If one warmed blanket has been provided the patient should be care- 
fully wrapped up in it. If there are two he should be laid on one, which 
should be brought up at the sides to cover the lower limbs, the top one 
being tucked in round the patient’s body. 

Before proceeding to complete the bedmaking, the nurse should notice 
whether the patient’s colour is good, whether his brealhing is deep and 
regular and w'hcther his pulse is satisfactory. She should then arrange the 
heating apparatus and the hot bedclothes over him. As far as possible a 
patient recovering from an anaesthetic should be screened from the view 
of other patients in the ward, but the screens should be so arranged that 
the nurses passing backwards and forwards up and down the ward can see 
the patient. If the patient is inclined to vomit or is at all restless the bed- 
side should not be left. In all cases the ward or room in which the patient 
lies should never be left until he is properly round from the general 
anaesthetic. 

Divided bed. This term is used to describe a bed in which the upper 
clothing which covers the patient is divided — usually about tlie middle. 
It may be used w'hen an examination of the lower part of the abdomen or 
pelvis is necessary, or when a dressing, or other treatment of this area, has 
to be carried out, for example, catheterization. It is also used in cases of 
amputation of the lower limb above the knee, and because of this use it is 
described by some authorities as an amputation bed. It is also conveniently 
used in preparation of a vapour or hot air bath, where the thermometer is 
hung from a cradle in the middle of the bed, and when, by means of 
divided bedclothes, this can more easily be seen. 

To prepare. For the purpose of making a divided bed the low'er bed- 
clothes are put on as usual, but for making the top of the bed two sheets 
will be required and two blankets. In some instances specially short blan- 
kets arc employed, in other instances sisters have been known to use cot 
blankets, or bath blankets for this purpose. 

To arrange the lower half of the top bedclothes, a sheet is placed length- 
ways over the patient and tucked in at the bottom; one blanket is laid on 
this, folded over so that it reaches to the level of the patient’s pelvis. The 
upper part of the sheet is folded down over this blanket and the bottom 
and sides cure tucked in. A second sheet is taken, also placed lengthways on 
the bed, and a blanket is placed on top of this sheet to cover the upper part 



8o THE CARE OF MATERIALS 

of the patient’s body. The lower part of this sheet is then folded up, over 
the lower edge of the doubled blanket, and the upper part of the sheet 
brought down over it to look like an ordinary sheet overlay. This part of 
the bwlclothes is then tucked in at the sides. 

It is important to arrange for the bedclothes to overlap from eight to 
twelve inches where they meet in the middle; unless contraindicated the 
lower part should overlap the upper part, so that as the patient moves and 
a little separation of the bedclothes may occur he does not feel that he is 
exposed to the gaze of persons in the room — this arrangement is also neater. 
The bedclothes can easily be separated for purposes of examination, in- 
.spection or treatment without unduly exposing or uncovering the patient, 
and this type of bed is particularly useful when treatment to the lower part 
of the abdomen, perineal area, or upper part of the thighs requires to be 
frequently repeated. Moreover, the necessity of making the bed each time 
— which proves not only trying to the patient, but exhausting to the nurse 
— is obviated. 

Should this form of bed be utilized in the case of an amputation of a 
lower limb above the knee, a small bedcradle should be placed over the 
stump and the divided bedclothes arranged around the stump but not 
over it (see next note). 

Amputation bed . This is a bed so arranged that the stump is visible to 
the nurses moving about the ward. It is specially necessary to have this 
arrangement in cases in which sepsis may occur and so give rise to the 
complication of secondary haemorrhage. Bleeding from a large vessel may 
prove rapidly fatal, and in the preparation of an amputation bed, there- 
fore, the first consideration is to provide a tourniquet conveniently near 
the bedside. It is necessary that every nurse in the ward should know how 
to use this tourniquet in case of emergency, as in sudden bleeding from 
an artery as large as one in the leg no time can be wasted seeking for 
help. 

In the preparation of an amputation bed, a long bed mackintosh is 
necessary for the protection of the mattress, and a short mackintosh 
covered by a drawsheet or towel should be placed on the bed under and 
around the area on which the stump is to rest. 

Sandbags encased in mackintosh covers should be provided, and laid 
against the limb in order to prevent its ‘jumping’, when twitching of the 
muscles occurs. These sandbags should be recently carbolized and they 
should be covered with special sterile covers, or wrapped in sterile towels. 
In addition, a sterile towel should be placed across the limb; the ends of 
the towel on each side should be secured in position by the weight of the 
sandbags placed on them. This acts as an additional restraint to involun- 
tary movements of the stump. Some authorities use a long, narrow, lightly 
filled sandbag placed across the limb above the stump for the same pur- 
pose. 

For the first twenty-four to forty-eight hours a pillow, which should be 
covered by a mackintosh and wrapped in a sterile towel, may be provided 
on which to rest the stump. In the case of a thigh it would lie in an 
elevated position against this pillow; but its use should be omitted as soon 
as possible as, if persisted in, flcxional deformity tends to occur at the hip 
joint, which may cause considerable discomfort and pain when it has to 
be corrected later before the patient can wear an artificial limb. 



SPECIAL TYPES OF BEDS 8 1 

In making an amputation bed the position of the stump has to be taken 
into consideration. If, for example, the amputation is above the knee, a 
divided bed as described above can be employed; but if the foot only has 
been amputated, at the level of the ankle, the stump may be allowed to lie 
on a pillow with a bedcradle over it and the bedclothes, arranged as in 
making up an ordinary bed, can then be turned back on the side on which 
the affected limb lies and arranged above and around the cradle and 
covering it, so that the stump is exposed to view. This turning back of the 
bedclothes allows air to enter the bed and may cause the patient to feel 
cold, but to prevent this either the good leg should be wrapped in a small 
blanket or a blanket should be placed next to the patient and wrapped 
well round him. 

Fracture bed. A bed in which a case of fracture is to be nursed, par- 
ticularly of the spine, pelvis or femur, must provide a firm unyielding 
surface on which the broken bone is to lie. For this purpose fracture 
boards may be used; these are boards fitted over the wire mattress and 
resting on the sides of the bedstead beneath the hair mattress. Either one 
large lathed board may be used, or several small boards with holes bored 
in them. In either case sufficient air will reach the mattress. 

Several appliances have been in use from lime to time in order to provide 
suitable bed accommodation for fractures. The Bradford frame was an early 
type of this apparatus, and more recently the Pearson bed has been used. 

Plaster bed. The term 'plaster bed ’ is used in two connexions -one in 
which a plaster of paris trough is employed for the patient to lie in, so that 
lie is rendered immovable on the bed — ^but the connexion in which it is 
used here indicates the preparation of an ordinary' bed in which a patient, 
who has had plaster of paris applied, is to be placed and nursed. 

As in the case of a bed for a fracture, this also requires to be firm and 
unyielding, particularly when the trunk is encased in plaster or when a 
plaster spica of the hip has been applied. In both these cases any sagging 
of the bed before the plaster was completely dry would be likely to cause 
deformity. 

Another point to be considered is that the bed should assist in drying 
the plaster. Plaster of paris is applied wet. It is not moved until it has set 
but, even after this, considerable evaporation of moisture must take place 
before it can be considered satisfactorily dry and hard. Arrangements 
should therefore be made so that the part encased in plaster is exposed to 
the air for evaporation and drying. In the case of a trunk in plaster, for 
example, a divided bed might be utilized, with bedcradles over the 
|)atient's trunk, and one or two inlets arranged to allow air to circulate 
freely around the body. In the case of a leg in plaster, having first wrapped 
the foot, if exposed, in cotton wool to prevent its getting cold, the bed- 
clothes might be turned back so that the entire limb is exposed, but a 
blanket should be placed next to the patient so that he is not chilled by 
this process. 

Some authorities require the addition of heat as an aid to the drying 
of the plaster of paris, and in this case when possible the bed may be drawn 
up near a fire or radiator; an electric cradle may be placed over it, or hot 
bottles may be used. 

The commonest modification of the hospital bed in a medical 
ward is the blanket bed. In this bed the patient should be lying between 



THE CARE OF MATERIALS 


82 

blankets; thin old soft blankets are best. The average drawsheet is 36 
inches wide, therefore this cannot be used or half of the patient's length 
will not be lying on blanket. It is usual either to double an ordinary draw- 
sheet, or to have narrow ones — 18 inches wide — ^specially made. An 
equally narrow strip of mackintosh is used beneath the drawsheet, imme- 
diately beneath the buttocks as they rest on the bed. This serves two pur- 
poses: (i) the usual protection of the under bedclothes from soiling during 
the use of sanitary utensils in bed, (2) tlie provision of a smooth cotton 
surface rather than a slighdy irritating fluffy one. 

A patient is nursed between blankets whenever he tends to perspire, as 
in rheumatism, so that the more absorbent woollen material will not result 
in chilling him, as would a cotton sheet; and also whenever extra warmth 
is necessary, as in diseases of the heart and circulation and in renal disease 
when it is desirable to assist the action of the skin by removing water and 
other waste matter in order to relieve the work of the diseased kidney. 

In a bed for rheumatism^ the blankets should be specially soft and absorbent 
as these patients perspire a great deal. Some form of heat may have to be 
provided such as hot water bottles; bedcradlcs wall usually be required 
to take the weight of the bedclothes from the aching joints and limbs, and 
pillows and sandbags to support the weight of the limbs in a comfortable 
position. 

In planning a bed for the reception of a case of acute rheumatism, care 
should be taken to see that it is firm and not liable to be moved by a slight 
touch, since every movement of the bed causes pain in such cases. 

A bed for a renal case should be warm, therefore hot water bottles may be 
required. The number of pillows required will depend on whether there 
is oedema — a patient with swollen legs, and ascites rendering his abdomen 
large and prominent, will require to be propped up on an inclined plane 
of pillow^s, as he will be unable to bend forward with any comfort. 

As patients w'ith oedema are readily predisposed to bedsore it may be 
necessary to supply a water or air bed. An air bed is preferable as it 
remains fairly warm, warmed by the heat of the patient’s body; but the 
great expanse of w^ater in a large size water bed is difficult to keep warm, 
it is useful to remove a gallon or two of water each day, replacing it by 
the addition of the same amount of water at 120° Fahrenheit. The air or 
w'ater bed should be beneath the bottom blanket. 

A bed prepared for a case of heart disease is often described as a heart or 
cardiac bed. The position in which the patient will be nursed depends 
entirely on the condition of his heart. In cases of acute heart disease ^ with fair 
compensation, they are best nursed flat; in this position the greatest rest is 
obtained. But in cases of chronic heart disease in which pulmonary symptoms, 
including dyspnoea, have developed, or in any case where decompensa- 
tion is marked, the patient may have to be propped up in order to breathe 
comfortably. 

The bed for a case of chronic disease of the mitral valve will, for example, 
require a bedrest, and several pillows, to support the patient’s back; a ring 
air pillow to protect the bottom of his back from pressure, a footrest to 
prevent his slipping down the bed and a bedtable or armrest in case 
he wishes to lean forward, as he may do when dyspnoea is so marked 
that the muscles of extraordinary respiration are continually in action, 
when this position, by fixing the shoulder girdle, makes their movement 
easier. 



THE USE OF BEDBLOCKS 


83 


THE USE OF BEDBLOCKS, BEDCRADLES, BEDRESTS 
AND BEDTABLES 

Bedblocks are used for raising a bed at one or other end. They are 
often made of wood, and vary in height from 4 to 24 inches. 

The foot of the bed is raised in the treatment of shock; in aiding the arrest 
of bleeding from the lower limbs, pelvis and abdomen; in the relief of 
oedema of the lower extremities and the vulva and scrotum and in order 
to assist in the administration of high colonic lavage or for the purpose of 
securing that an enema be retained. 

The head of the bed is raised in treatment for the relief of bleeding from the 
head and chest; as an aid in respiration in cases of dyspnoea, when this 
position assists breathing by causing the diaphragm to be slightly lower. 
It is also used when drainage from the lower part of the abdomen or the 
pelvis is necessary. 

In putting blocks in position it is advisable to arrange them near the 
bedposts under which they are to l)e placed, one or two nurses elevating 
the end of the bed while another places them in position. The bed should 
be steadied on the blocks before the weight is released, in order to ensure 
that the bed is firm. In lifting a bed down from blocks, the same careful 
handling is necessary; the bed should not be moved quickly, but lowered 
slowly and deliberately. 

Bedcradles arc appliances which are provided for the purpose of 
(’Icvating the weight of the l)cdclothes from the patient's body. They may 
1)0 applied over a limb which is painful, or may be used to relieve the body 
of the weight of the clothes in cases where breathing is difficult, or when 
the patient is uncomfortable and rcstldi. They are also employed when 
it is desired to suspend some articles a little distance from some part of the 
patient’s body, as in applying an icebag suspended over the epigastrium 
in the relief of haematemesis. 

Bedcradles may be made of wicker, light wood, wire or fine metal tubing. 
Wicker ones are light, and when metal cradles arc employed care must be 
taken to see that no hot appliance in the bed comes into contact with the 



Fio. X I 

When a cradle is put in the bed, place a blanket or sheet next to the patient, otlxcrwisc 

he may feel cold. 



84 the care of materials 

metal, for fear lest the heat, rapidly conducted, might burn the patient 
should he touch the bedcradle. 

Bedrest. A bedrest or backrest is a light wooden or wicker frame, or 
canvas or cane covered frame placed obliquely behind the patient as he 
sits up in bed; pillows arc arranged on this form of support against which 
the patient rests. It is probably provided for economy of pillows; some of 
the more modern hospital bedsteads have the back of the bed arranged on 
a hinge which permits it to be swung forward to form a similar type of 
support. 

A patient supported on a bedrest may need an air ring cushion, as the 
lower part of his back is apt to become sore from continuous sitting. His 
head should be supported by a specially soft pillow placed at the nape of 
his neck — otherwise his neck muscles will grow tired of supporting the 
weight of his head. When the head of a patient nods backwards and for- 
wards it is reasonable to suppose that he was placed in position by a nurse 
without the necessary imagination for visualizing this particular form of 
discomfort. 

Bedtables. Small tables are provided which fit across the knees of a 
patient as he sits up in bed; they may be employed for meals, or for reading 
or other light work, but when one is used for him to lean forward on, in an 
effort to assist very difficult breathing, it is often described as a heart table. 
When a patient with dyspnoea has to sit in this position for a considerable 
time it is important to take care that, as he leans forward, the lower part of 
his back is supported by a pillow, and that his back, shoulders and arms 
are covered by a light warm wrap. When a bed table is used as a heart 
table it must have feet or castors w'hich can be fixed, so that it will not 
move wfficn the patient leans oo^t. 

Some tables have a head rest provided, and this should be padded; it is 
movable and can be raised and lowered so that the patient s forehead is 
properly supported as he sits. 

FILLING AIR AND WATER BEDS AND PILLOWS 

Full-size air and water beds are used in cases of helpless patients wffio are 
liable to bedsore. In some instances cushions or ring pillows are utilized. 

Ip filling water beds and pillows, the article should be placed in the 
position in which it is to be used on the bed in which fracture boards have 
been placed. The water is then brought to the bedside in jugs and the bed 
filled, using a funnel. In the case of small cushions they may f>e filled in the 
bathroom on a flat board on which they are carried to the bedside, to pre- 
vent their doubling up and so allowing the weight of the water to fall on 
one part of the rubber, straining it, and reducing the length of service of 
the article. In both cases the bed or cushion requires to be only partly 
filled. All air must be expelled, the stopper screwed down and the bed 
tested as follows: Pronate lioth forearms and place them on the bed as it 
lies on the board. It should be possible to make an impression with both 
arms and, with one, the hard surface beneath should be distinguished. It is 
a very good plan lor every probationer who is being taught to fill these 
articles, to practise filling a cushion and sitting or lying on it, letting the 
air or water out as the case may be until she considers it comfortable. She 



FIU.ING AIR AND WATER BEDS 85 

will be surprised at the little inflation that is necessary and would never 
have believed it without this experience. 

In Ailing air beds, either a footpump or a handpump should be used, 
i'his is advisable also in filling cushions, but there may be occasions when a 
nurse will be faced with the difficulty of filling a cushion without this 
appliance, in which case she should blow it up by mouth, covering the 
nozzle with a piece of gauze in order to protect her lips. All air cushions 
and beds should be tested if there is any doubt about them by placing in 
water after inflation, when if a hole is present the air will bubble through 
into the water. 

When large water beds are used, the temperature of the water should 
be about 105° F. The bed should be covered with a blanket as its surface 
is apt to get chilled and strike cold to the patient. Sometimes a water 
cushion or pillow filled with water at a temperature of 120" is used in the 
treatment of shock in infants, as it provides a large w’arm surface on which 
the infant can lie during treatment. 

Water beds and cushions when in use require emptying and refilling 
every fortnight as the water tends to decompose. Some sisters aim at 
obviating this by putting a little formalin in the water. 



Chapter 6 

Positions Used in Nursing 

The positioris described are: — Supine — Prom — Semirecumbent — Fowler's — Left 
lateral — Sims's semiprone — Lithotomy — Trendelenburg's — Rose's — Genu^-pectoral 
— Orthopnoeic — Hyperextension — Nelson's bed 

T he positions used in nursing vary with the needs of the patient — as 
a rule patients are nursed in recumbent, semirecumbent or erect 
sitting positions. Nurses would have no difficulty in realizing the 
possible uses of the various positions and the best way of maintaining them 
in comfort, if they would devote half an hour to placing themselves in the 
different positions. The practice becomes very interesting when a group 
work together, putting one another in the various positions, and usually 
results in wholesome firsthand criticism of the manner of handling and 
moving the model. 

The dorsal recumbent or supine position is lying flat on the back 
with one soft pillow, the knees being straight or very slightly flexed over a 
pillow. This position provides for full relaxation and is the one in which 
many acutely ill patients are nursed. It is contraindicated in elderly per- 
sons, or any who may be subject to bronchitis, or liable to contract 
hypostatic congestion of the lungs; also in all surgical abdominal cases 
where drainage is necessary, and after operations on the breast or thorax, 
and in a great many other conditions. It is also contraindicated in most 
long-standing illnesses and in neurological conditions, as it is apt to become 
depressing — partly because of the difficulty of carrying on any little 
occupation in this position, and partly because the patient is not able to 
see and take an interest in the life which is going on around him. 

This position is also used for examination of the front of the trunk, but 
for examination of the abdomen the knee pillow should be removed. It is 
also used for examination of the rectum and vagina provided the thiglis 
are flexed and outwardly rotated. 

Prone recumbent position. In this position the patient lies on the 
front of the body, A pillow is placed beneath the chest, and usually one 
arm lies beneath the body in a hollow below this pillow. A second pillow 
is provided on which to rest the side of the face, the arm on the side to 
which the face is turned lying flexed beside this pillow. 

This position is not very often employed; it is useful when there is danger 
that bedsores may form on the back, and it also prevents and relieves 
flatulent distension; it is occasionally used to facilitate drainage from the 
front of the body, as for example in the case of a peri-umbilical abscess. 

Dorsal elevated or semirecumbent position. The patient lies on 
his back with his chest raised on several pillows. It can also be main- 
tained by elevating the top of the bed on blocks so that the patient lies on 
an incline. This position is freely used, both in medical and surgical nurs- 
ing. It is the one in which most gastric cases arc nursed, most chronic and 

86 



POSITIONS USED IN NURSING 87 

subacute and some acute chest conditions; many patients after a general 
anaesthetic and abdominal or pelvic operation, unless the erect sitting 
position is indicated, and practically all convalescent patients favour this 
position. 

A pillow is placed beneath the knees and secured to the sides of the bed, 
or it may be rolled in a drawsheet which can be firmly tucked under the 
mattress at the sides to keep it in position, or the ends of the drawsheet 
may be twirled round, tied with cord and fastened to the top of the bed. 
In some instances a footrest is employed. All these devices are designed to 
prevent the patient from slipping down and so assuming the recumbent in 
place of the semirecumbent position. 

Fowler’s position. This position was introduced by an American 
surgeon who elevated the top of the bed on 24-inch blocks, and so secured 
a semirecumbent position (q.v.); but for all practical purposes what is 
described as Fowler’s position in England is a more erect one in which an 
effort is made to maintain the patient in a sitting posture as nearly upright 
as possible. 

The position may be maintained by means of the Lawson-Tait Fowler- 
position bed^ or by propping the patient up by means of backrest and pillows, 
or by using only pillows. The arms should be supported on pillows so that 
the patient sits with his forearms supported, as in an armchair. As he is 
sitting erect a ring air cushion is frequently employed to prevent soreness 
over the sacrum. When pillows are used, a knee pillow is employed to help 
maintain the position arranged as described in the semirecumbent 
position. 

Uses. This position is used whenever drainage of the abdominal cavity is 
desired, and in most cases after operation on the upper part of the stomach 
and duodenum. It makes breathing easier in cases of dyspnoea, by 
facilitating the movement of the diaphragm and therefore aids expansion 
of the lungs, and for this reason is employed in many chronic and in some 
acute conditions of the chest. 

Left lateral position (see fig. 30, p. 154). This must not be confused 
with Sims’s position (see below). The left lateral position is used when a 
patient is turned on to his side for purposes of washing and rubbing his 
back as in the routine treatment for the prevention of bedsores. It is also 
frequently used for giving any form of enema, for the insertion of a sup- 
pository, the taking of the temperature by the rectum, or for any treat- 
ment to, or examination of, the perineal region, 

Sims’s semiprone position (see fig. 31, p. 154) is one in which the 
patient lies partly prone, and on her left side. Her right arm lies on tlie 
bed in front of her and the left is behind her lying on the bed on which 
she lies. Both knees arc drawn up, the right being rather more flexed 
than the left, and lying on the bed in front of it, thus rendering the 
[)osition fairly steady. The left side of the face rests on a small pillow placed 
under the check. 

This position is used for examination of the vagina; the effect of it is to 
rausc ballooning of the vagina when a Sims’s speculum is introduced, thus 
iacilitating examination of the vaginal walls. It is also useful when a rectal 
treatment is to be undertaken, should it be considered necessary for the 
anus to be more clcaily visible than is possible in the left lateral position. 



88 POSITIONS USED IN NURSING 

Alternatively a modified left lateral position, as shown in illustration, 
fig, 32, p. 155, may be used for examination of the vagina. 

The lithotomy position is obtained by flexing the hips and knees as 
the patient lies supine; the pelvis is raised and brought down until the 
sacrum rests on the edge of the table upon which the patient lies. The 
position is maintained by special devices attached to many operating 
tables, or by means of Clover’s crutch. 

It is used for examination of the genito-urinary tract, and for operations 
on the lower part of this, the rectum and the perineum. 

Trendelenburg’s position. In this, the top and centre of the table is 
tilted so that the head is lower than the pelvis; the lower end of the table 
is hung down at right angles and against it the legs are fixed at the ankles. 
All modem operating tables are movable, and the best way to obtain this 
position is to fix the patient’s ankles only on to the lower flap of the table 
as the legs lie, with the knee joints of the patient exactly over the hinge 
of the table, so that when the end is let down at right angles the legs are 
flexed, as when sitting on a chair. Unless the ankles are fixed the patient 
will slip down into the anaesthetist’s lap when the table is tilted, and if this 
happens an attempt to fix the knees will result in pressure on the peroneal 
nerv'e; but if the ankles are firmly fixed the straps can only impinge on the 
soft parts of the calf of the leg and thus pressure on this nerve as it passes 
over the head of the fibula will be avoided. 

Some tables have shoulder rests, and if these are used they require care- 
ful adjustment for each patient, otherwise the trunk may lie so heavily 
against these rests as to cause pressure on the brachial plexus of nerves, 
resulting perhaps in paralysis of the arms, which may seriously disable 
the patient long after he has recovered from the effects of the operation 
which he has undergone. Two important points have therefore to l>e con- 
sidered in getting a patient into Trendelenburg’s position, but if these are 
attended to the surgeon is relieved of anxiety and the patient of possible 
serious injury. 

Trendelenburg’s position is used during the performance of operations 
through the anterior abdominal wall, and on the organs of the pelvis and 
lower part of the abdomen. It is also used in the treatment of syncope 
during anaesthesia. 

Placing the foot of the bed on high blocks obtains a similar position, 
and this is used in the treatment of shock and in the arrest of bleeding from 
the lower limbs. 

A position the leverse of Trendelenburg" s is employed for operations on the 
organs of the upper part of the abdominal cavity. 

Rose’s position is one in which the head of the operating table is let 
down so that the head hangs over it. It is used in operations on the mouth 
and throat, as in the removal of tonsils and adenoids, in order to prevent 
blood from entering the larynx. 

Genu -pectoral position. In this position the patient rests on his 
knees, arms and chest. To obtain it, he is asked to kneel on the bed and, 
keeping his thighs upright, to bend forward until his chest rests on the 
bed; he then places his arms in yard-position on each side of his head. His 
head is turned to one side and his face rests on a small pillow. This position 
is used when the effect of gravity is employed as in the administration of 



POSITIONS USED IN NURSING 89 

high colonic lavage and also in visceroptosis, in which case the patient is 
asked to occupy this position for several intervals during the day in order 
to assist in replacing the dropped organs. 

Orthopnoeic position. This is used in cases of dyspnoea, usually of 
heart disease, when the patient is unable to obtain any relief and finds it 
extremely difficult to breathe unless he is sitting up and leaning forward. 

The erect sitting position is maintained by means of backrest and pillows. 
In addition the patient is given some form of support, such as a bed table, on 
which to rest his arms in front. In some cases a headrest on which the 
forehead can be placed is also provided. Nurses will notice the nodding 
movements of the head which occur w'ith every respiratory act when 
dyspnoea is marked, and the provision of a headrest in such cases adds 
considerably to the patient^s comfort. 

Hyperextension is used in the treatment of some forms of spinal 
disease, but as a rule some apparatus is utilized to maintain the position. 

Head suspension may be used in diseases and injuries of the neck, but 
in this case also some form of fixation is employed, to obviate the difficulty 
of maintaining immobility during the performance of the various neces- 
sary nursing measures. 

Postural drainage is the placing of a patient in such a position that 
secretion (sputum) drains out of the cavities of the lung in the case of 
tuberculosis, and out of the dilated alveoli in the case of bronchiectasis. 
The lower lobes are most often affected and the method of tipping shown 
in the Nelson bed (fig, 33, p. 155,) is that adopted. The upper lobe drains 
best when the patient is sitting up. The middle lobe drains when the 
patient lies Hat, and the back parts of the lobes when the patient lies on his 
lace. The physician will inform the nurse which lobes are affected and 
in what position he wishes the patient to be placed for postural drainage 
purpo.ses. The patient usually lies in the special position required for 
several long or short intervals during the day. 



Chapter 7 

Local Applications 

Fomentations and stupes — Applications of cold^ icebag^ cold compress^ evaporating 
dressings Leiter's coil^ ice poultice — Poultices and plasters: antiphlogistine, linseed^ 
musiardy charcoal and starchy mustard plaster^ belladonna and opium plasters — 
Liniments — Ointments and glycerines — Application of a leech — Counterirritants: 
rubefacients^ vesicants and aipping 

L ocal applications are applied for many purposes- — they may be hot 
or cold; contain antiseptic, sedative, stimulating, soothing or 
^ antispasmodic substances. They may be applied in a number of 
different ways, including fomentations, plasters, poultices, evaporating 
dressing, wax dressing, liniment and paint. 

HOT APPLICATIONS 

Applications of heat may be applied dry, or moist; the latter are con- 
sidered to be more penetrating than dry applications. 

Fomentations are also called stupes in some instances; a fomentation 
may be a surgical dressing, either when applied in an aseptic manner or 
when of an antiseptic nature; it may be used as a medical treatment in 
order to provide moist heat and in this case a simple fomentation is 
employed. 

A medical fomentation can be made by wringing out a piece of old 
flannel or blanket in very hot water. Any soft absorbent material may be 
used, when wrung out it must be shaken to allow the steam to escape so 
that the patient may not be scalded. When applied every few minutes 
there is no need to cover this dressing; but when applied at intervals of 2 
hours or so, it is usual to cover it with either a piece of dry absorbent 
material or a piece of waterproof. 

To prepare and apply a fomentation a wringer is used (see fig. 34, p. 1 56) . 
The fomentation is then removed from the wringer and shaken to let steam 
escape. A fomentation must not be applied over Vjroken or abraded skin. 
The fomentation may be covered by a piece of dry flannel or by cotton 
wool, or a sheet of jaconet may be placed over it, which may also be 
covered by cotton wool. In all cases the covering material should be larger 
than the fomentation as the purpose of the former is to retain the heat 
(see fig. 35, p. 156). The application is then bandaged on. 

Medical fomentations may be changed every hour or every two, three 
or four hours. Before changing, the old one should be removed and the 
skin carefully inspected to see if it has been too freely reddened. In all 
cases in which the skin is tender it should be smeared with a little vaseline 
or olive oil before the moist application is made. If any interval of time 
should elapse between the removal of one hot dressing and the application 
of the next the area should not be left exposed, but should be covered 
with a layer of warmed cotton wool until a fresh application is made. The 


go 



HOT APPLICATIONS 


91 

material used for this type of fomentation may be dried and used over 
again. It is usually convenient, when employing medical fomentations, 
to have two or three pieces of flannel or blanket in use alternately, but the 
material should always be quite dry before being used again — otherwise 
the cold wet material will cool the water and the fomentation will not 
be quite as hot as it might be. 



Take hold of tlic wringer as shown in the upper drawing, then twist and stretch; this 
wrings out the water. Keeping tlie grip witli the left hanci, take again the first position 
with tlie right, and repeat wringing until all water is squeezed out. 

Alkalme or soda fomentations are sometimes ordered in the treatment of 
painful arthritic or rheumatic conditions. A teaspoonful or two of sodium 
bicarbonate is sprinkled over the fomentation before the water is poured 
on. The amount depends upon the size of the fomentation and the nurse 
should try to manage so that one or two tcaspoorifuls are used with each 
pint of water. 

Hypertonic saline fomentations. These may be ordered for the relief of ten- 
sion of the tissues when congestion and swelling are causing pain, as in 
cellulitis. Two drachms of salt or magnesium sulphate are added to the 
fomentation for each pint of water used. As the skin is tense it is advisable 
to smear it with liquid paraffin or olive oil before applying the hot moist 
application. 

Sometimes a drug which may be of either a soothing or an irritating 
nature is added to a medical fomentation, and this form of application is 
often described as a stupe. The drugs most commonly employed are opium 
as a sedative, belladonna as an antispasmodic, and turpentine as an 
irritant* 

Turpentine stupe. Preparation is made as for a medical fomentation, and 
from two to four drachms of turpentine are sprinkled on to the flannel before the water 
is poured over it. Although this method is almost universally used, it has one 
disadvantage in that the turpentine may not mix freely with the water, 
and therefore not be well diffused over the whole dressing. This disadvan- 
tage will be obviated if, instead of sprinkling the turpentine over the 



LOCAL APPLICATIONS 


92 

flannel, one or two drachms of turpentine mixed with a little olive oil arc 
smeared on the skin over which an ordinary medical fomentation is then 
applied. As turpentine is a very powerful irritant the skin will be reddened 
fairly quickly—some skins being more sensitive than others — and the 
nurse should raise a corner of the dressing 10 or 15 minutes after its appli- 
cation, and at intervals following its application. When the skin is well 
reddened the dressing should be removed and the skin wiped over with oil 
or alternatively dried and powdered, and some warm cotton wool then 
lightly bandaged on. * ^ 

A turpentine stupe may be used as a counterirritant in cases of bron- 
chitis, pleurisy and pneumonia to relieve pain in the chest. It is also 
frequently ordered for the relief of abdominal distension. 

Opium stupe. When preparing this application from 20 to 60 minims of 
tincture of opium are sprinkled evenly over the flannel after it has been 
wrung out. This method is used to conserve the drug which is readily 
soluble in water, and the opium is used as a sedative application. 

Belladonna stupe. This may be prepared in exactly the same way as an 
opium stupe, using tincture of belladonna in place of opium, an alterna- 
tive method being to paint the skin with glycerine of belladonna, and then 
to apply a medical fomentation over this. Belladonna is a sedative, but is 
also very valuable for its antispasmodic properties, being used for the 
relief of pain and particularly that of lumbago. 

Surgical fomentation. This is a form of aseptic dressing which may 
be applied over the wound, either boracic or white lint being used. The 
articles required include sterile towels, wool and swabs, Cheatle’s forceps 
in lotion, sterile instruments such as those suitable for the performance of a 
simple surgical dressing, dissecting forceps, sinus forceps, pointed scissors, 
probe and artery forceps. Some antiseptic lotion in a sterile bowl for 
cleansing the wound and receptacles for soiled dressing and used instru- 
ments should be provided. The fomentation should be prepared ready for 
boiling (see fig. 36, p. 157) and a bandage should be supplied. 

To prepare the fomentation^ a double fold of lint is placed in a wringer, 
which is then put into a sterilizer or saucepan, with the ends hanging out 
over the sides, and the dressing is boiled. After boiling for 10 minutes the 
fomentation is wrung dry and handed to the doctor or nurse who is to apply 
it. He or she lifts the fomentation out of the wringer — using two pairs of 
forceps — shakes it as before described in order to free the material of all 
steam and then applies it. This dressing may be covered by a piece of 
sterilized wool or jaconet and wool, and bandaged on. 

An antiseptic fomentation may be made by using i /80 carbolic, a weak 
solution of perchloride of mercury or lysol, instead of water, in which to 
wring the fomentation. 

Hot dry applications may be made by means of a rubber hot water 
bottle, but great care must be taken not to burn the patient, and it is 
inadvisable to have the water hotter than 120"^ F., as the patient is very 
likely to hug it closely to himself. The bag should be covered with a flannel 
cover. 

The next most commonly used form of dry heat is an electrically-heated 
compress made of flexible material which can be adapted to the surface of 
the body. It is fitted with a heat regulating switch on the wall plug adjusts 
ment. 



HOT APPLICATIONS 


93 

Another method of making an application of dry heat is by means of a 
bran or salt bag^ which is just a small cushion lightly filled with bran or salt, 
heated in an oven between two enamel plates and applied reasonably hot. 
Care must be taken to avoid injury to the skin. 

APPLICATIONS OF GOLD 

Cold applications are frequently used in order to limit inflammation, 
especially when of non-bacterial origin, and in the early stages of injury. 
Cold is useful in limiting the effusion, which rapidly follows on injury, 
especially injury to a joint; it is also effective in the diminution of bleeding 
when applied over the bleeding part, and will relieve congestion — as in 
cerebral congestion and cerebral haemorrhage — and it is sometimes used 
for the relief of pain. Most cold applications require the addition of ice. 

Ice is fairly often used in nursing, either as an application of cold, or for 
patients to suck if they especially wish to have it, although this is not 
advisable as it tends to crack the lips. 

It is possible that a probationer nurse will feel rather appalled when 
first she secs a block of ice with which she is expected to deal, and she may 
be quite at a loss how to tackle it. Ice is best kept in a piece of blanket 
unless an ice chest is available. A large block may be broken by striking 
it with a hammer whilst it is wrapped in a piece of blanket — the use of the 
blanket deadening the sound and preventing splinters from flying about. 
Small pieces arc most easily broken off, cither by using an ice pick, or a 
strong pin — a small hatpin, for instance, such as nurses frequently wear 
to keep their caps in position. In order to deaden the sound when breaking 
ice the block should stand on a double fold of old blanket, either on a plain 
deal table or on a block of wood. 

Icebag. An icebag is the commonest form of cold application used, and 
it is frequently applied to the head in cases of cerebral haemorrhage, or to 
relieve headache when this is due to congestion. Nurses frequently forget 
the value of an icebag in this respect, yet they will not be backward in 
suggesting contemptuously that a contemporary who is studying hard 
might put a wet towel on her head! An icebag is also applied locally as an 
aid in the arrest of bleeding. 

Icebags, or icecaps as they are most often called, are made of rubber, and 
are of different shapes and sizes though generally they arc round or oval. 
Some are helmet-shaped for close application to the head, and long 
narrow ones are supplied for use round the neck. 

To fill an icebag (see fig. 41, p. 159), first inspect it to see that it has no 
holes and that it will hold air when inflated — that it is not perished, and 
that the screw cap fits and has an adjustable rubber ring for greater 
security. 

The ice is prepared by chopping it into convenient pieces about the size 
of a walnut, and if allowed to stand a moment or two any sharp corners 
which might injure the bag will disappear. Sprinkling salt over the pile of 
prepared ice will make a better freezing mixture. The ice is then put into 
the bag until the latter is half full, and the bag is grasped by one hand, the 
air expelled and the stopper screwed on. The surface of the bag should be 
wiped dry, and it is then put into a flannel bag which should fit well, or it 
may be wrapped in a piece of flannel, and applied to the part ordered. 



94 LOCAL APPLICATIONS 

An icebag should rest lightly on the skin, and except in the case of the 
head it should always be suspended from a cradle so that, although the covered 
bag touches the skin, the patient docs not receive the weight of it. In cases 
of meningitis when an icebs^ is applied to the head it is advisable to take 
the precaution of tying the bag to the rail or head of the bed, 

Icebags should be kept half filled with ice, the nurse watching to see 
how often it needs replenishment, which will depend on the temperature 
of the patient and the heat of the part to which application is made, and 
also upon the size of the bag that is used. The skin over which tlie applica- 
tion is made should be inspected for mottling, which would indicate that 
the application should be ^scontinued for a time. The neglect of this pre- 
caution might in certain cases result in gangrene and frostbite. 

To store an icecap. Like other rubber articles it should be handled from 
time to time to preserve its elasticity, and when empty it should be drained 
until dry and then mopped out with a soft cloth to ensure this. It should 
afterwards be slightly inflated with air so that the interior surfaces of the 
rubber do not lie together, and it should be kept in its own cover or 
wrapped in a piece of material to protect it as it lies in the box in which it 
is kept. 

Compress. Two types of compresses are commonly employed; one 
described here as a cold compress, and the other as a moist dressing, 
because it is not always kept cold. 

Cold compress. A single layer of material which permits of evapora- 
tion is essential for the application of a cold compress. This is a means of 
keeping a part cool by evaporation of water from the material used, and 
when once a nurse realizes this point she will not attempt cither to make 
use of a double fold of material or to cover the material up. 

The linen used is wrung out of iced water, laid on the part affected, and 
then changed as soon as it is warm. This type of compress when used as an 
application to the forehead may relieve headache. When applied to a 
sprained joint it will limit elfusion of fluid into the joint, and so relieve 
congestion and pain. 

In all cases a compress should be changed frequently — when a very 
small dressing is used, as in the case of an eye, a dozen applications may be 
prepared at once and, having been wrung out of water or lotion, be placed 
lying ready on a block of ice at the bedside. This treatment is usually 
ordered to be given for say 15 minutes every hour, changing the compress 
every 30 to 60 seconds in order to ensure constant application of cold, 
and it therefore requires a nurse in constant attention at the bedside. 

When the area treated is larger, and the congestion less severe, the com- 
press may be changed once every 10 or 15 minutes, as when an application 
is made to a sprained ankle. 

Moist dressing. This is applied by wringing out two or three layers of 
some soft absorbent material in cold water. Lint, flannelette or linen, with 
a layer of wool sandwiched between two layers, may be used, and this 
dressing can be retained in position by means of a gauze bandage. It is 
changed every half-hour or every hour, is soothing when applied over pain- 
ful parts, and is particularly valuable for relieving pain and discomfort 
in catarrhal laryngitis. 

Evaporating dressing. Evaporation and consequent chilling is more 
rapid when spirit is applied to the water — a mixture of one part of spirit 



APPLICATIONS OF GOLD 95 

to three parts of water being very usual. Methylated spirit is frequently 
used, but as this has an unpleasant odour a little lavender water might be 
added. 

Various evaporating lotions arc used, a fairly common one being a 
mixture of lead and opium which is applied for the relief of very painfully 
bruised or congested parts. 

Leiter’s coils. By means of coils of flexible material such as lead or 
rubber, a continuous application of cold may be made to a part, iced 
water being constantly run through the coil. 

To apply* The arrangement of coils is applied to the skin over a layer of 
lint or flannel, and secured in position either by straps or bands which are 
attached to tlae apparatus; or it may be lightly bandaged on, provided 
that when rubber is used the pressure is not sufficient to compress the 
tubing. A length of rubber tubing — a yard or two — passes from each end 
of the coil, and a sinker is attached to the distal end in each case. One end 
of tubing is placed in a receptacle above the level of the patient’s head. It 
may be hung from the bedrail or from the top of the locker, or suspended 
by means of a bedside stand. This receptacle contains water in wWch large 
pieces of ice are placed, large pieces being used since these will not melt so 
rapidly. The water then flows, by siphonage, through the coil of tubing 
which is lying on the patient, and by means of a second length of tubing is 
carried from the lower end of the coil into a receptacle which stands on the 
floor by the bedside. It is important for the nurse to sec that the receptacle 
from which the water is running does not become empty. A very easy way 
of managing this method of treatment is to alternate the upper and lower 
poles — for example, by deviating the bedside pail when it is full of water 
and placing the upper one, now almost empty, on the floor. Large pieces 
of ice are placed in the water in the pail which now becomes the receptable 
from which the water is flowing. 

Ice poultice. This form of cold application may be made to a small 
area as in the case of an eye, instead of applying cold compresses; or it 
may be made to a large area in cases in which a cold application is made 
to the chest, for example, in cases of pneumonia. 

To prepare. Two pieces of guttapercha arc chosen, of the size required 
for the application, with a thin layer of wool on one piece, which reaches 
within half an inch of the edge of the tissue all round. Ice is chopped into 
small pieces, sprinkled with a little salt as in filling an icebag, placed 
evenly on the layer of cotton wool and covered by a second similar layer, 
and over this is placed the second piece of guttapercha tissue. The edges of 
three sides of tissue are now moistened either with chloroform or turpen- 
linc pressed together and so sealed, since either of these substances dis- 
solves the tissue and makes it slightly tacky. The air is then carefully 
]:>rcssed out of the poultice, and the fourth margin is sealed in the same 
way. 

To apply* As in all applications of cold, it is necessary to see that the 
patient’s skin is free from abrasions and that there is a layer of lint or flan- 
nelette between the application and the patient’s skin. The poultice 
should be renewed as soon as the ice melts. 

As guttapercha tissue is rather expensive, the pieces used need not be 
discarded, but the sealed margins may be cut off and the good pieces 
used again. This will render the second application only slightly smaller. 



96 


LOCAL APPLICATIONS 


POULTICES AND PLASTERS 

A poultice or, as it is also called, a cataplasm^ is a hot application of moist, 
soft consistency, made of some mealy substance which retains heat com- 
paratively well. Limeed meal is commonly used for this purpose, with 
mustard in some cases added to it to render the application more stimu- 
lating to the circulation. 

A plaster^ or emplastrum — not necessarily a hot application — usually 
consists of a paste tacky in substance and containing drugs which may be 
either irritating or soothing in character. The best examples are belladonna 
and opium plasters applied as soothing applications, and a mustard plaster 
used as a counterirritant. 

Antiphlogistine is a preparation of clay and is used in the method of 
applying heat most common today. The clay contains a number of volatile 
oils, including methylsalicylate, and is supplied ready prepared in tins. 
The length of time it retains heat as compared with other forms of poul- 
tice, and the volatile substances which it contains, render it a very 
favourite application. Alternatively, cataplasma kaolin co. is used. 

The articles required for the application of antiphlogistine include the neces- 
sary amount of clay in an upright container which can be heated in a 
saucepan of water over a stove or gas ring, but it is important to sec that 
the bubbling water does not run over into the clay. The contents of the tin 
should be stirred by a metal spatula so that it is heated evenly throughout, 
and the nurse will test the heat from time to time by lifting some antiphlo- 
glstine on the spatula and applying it to the skin of her forearm. 

\ poultice hoard is required and some lint or flannelette^ on which to spread 
the mixture, together with a pad of wool to cover the poultice and a bandage 
or binder and safety pins with which to secure it in position. 

To apply. The clay may be spread directly on to the patient's skin, which 
should be free from abrasions or cuts, and covered by a thin layer of wool, 
which is a very comfortable method provided the application is not too 
hot; but the more practical method is to spread the antiphlogistine with 
the heated spatula on to the smooth side of a piece of lint to about half an 
inch in thickness, leaving a margin of an inch or more all round the edge. 
The edges of the lint should not be turned over on to the clay as this 
would make a hard bulky edge which soon becomes uncomfortable when 
the application is worn. The poultice is then covered by a piece of warm 
fluffed-up cotton wool and lightly bandaged on. 

When the poultice is removed the skin should be washed and gently dried, 
and any little bits of dried antiphlogistine adherent to the skin should be 
removed with olive oil swabs. The skin should then be powdered and 
covered with warm cotton wool, secured in position by means of a gauze 
bandage. 

Linseed poultice. As this poultice must be applied hot, all the utensils 
used for the preparation of it should be placed in hot water to become 
thoroughly heated, and the linseed should be warm. Care should be taken, 
however, only to warm the amount of linseed meal that is required, since 
repeated warming tends to dry the meal by removing the volatile oils. 

The articles required (see fig. 37, p. 157) are, linseed meaf ready warmed 
in a bowl, and olive oiL A small bottle of olive oil, holding about two 
ounces, should be at hand in the poultice cupboard. The oil should be 



POULTICES AND PLASTERS 97 

heated before it is used, and this little bottle may be heated by standing it 
in hot water. The olive oil may be used to spread on the surface of the 
poultice as described below, or else it may be smeared over the patient’s 
skin before the poultice is put on. 

A metal spatula should be standing ready in a jug of hot water. 

Some teazled tow or linen will be required, on which the poultice is to be 
prepared. Tow is best, as the air between the flulfed-out particles of it acts 
as a good non-conductor of heat and helps to retain heat in the poultice. 
Moreover, tow is lighter and warmer than linen. 

A poultice board will be required on which to prepare the application, and 
either two earthenware dinner plates rc^idy warmed, or a warmed bowl or warm 
towel — any one of these can be used for conveying the poultice to the bedside. 

A layer of wooly larger than the poultice, should be supplied to cover it. 
Some sisters use jaconet, but this is not invariable as many of them think 
that the employment of jaconet over any hot moist applications is apt to 
make the skin sodden. 

A bandage or bindery and safety pinSy will be needed to retain the poultice 
in position. 

To make and apply the poultice. The required quantity of boiling water 
should be poured into the earthenware bowl in which the poultice is to be 
mixed. Only experience will teach how much water will be required, but 
roughly half a pint of water will make a poultice for the throat while 
about a pint and a half will be needed for a poultice for the chest. 

The warm linseed is then put into the water in handfuls until the water 
appears to be well soaked up. The mixture should now be stirred with the 
metal spatula and the nurse continues to sprinkle linseed meal into it 
until the mixture begins to leave the sides of the basin. She then stirs it 
thoroughly well, not taking too long about it, as steam is rising all the 
time and the mixture is rapidly becoming cool; she turns it out on to the 
prepared tow which is lying on the poultice board, and spreads the mix- 
ture evenly but quickly to the desired thickness, which varies, but for 
average purposes may be from about a quarter to half an inch in thickness. 
Finally, the nurse pours a little of the warmed olive oil over the entire 
length of the blade of the spatula and, with one clean sweeping stroke, 
smears this oil in a thin film across the surface of the poultice. The tow is 
then turned over the edge of the linseed all round with the same rapid 
twisting movements that a cook uses when she twists paper over the rim 
of a jar or jampot. The poultice is placed on the wool on which it is to be 
applied; it may be rolled or folded and then put into the article which has 
been provided for carrying it to the patient’s bedside. 

Having reached the bedside the nurse informs the patient that she has 
l)rought his poultice, exposes the part to which it is to be applied and in- 
spects the skin to see that it is quite free from any abrasion or injury. If the 
poultice is to be applied to any part of the trunk, she first places the binder 
ready in position, and then unrolls the poultice and tests its heat on the 
skin of her own forearm, and applies it gently to the patient’s skin, lifting 
it off and on, and not permitting the weight of the poultice to lie on him 
until he can bear the heat of it. She must encourage him in this and should 
judge more by the degree of redness the heat causes than by the patient's 
opinion, because some patients are afraid of being burned and will not 

| ))ear anything; while others, overanxious to help, will willingly bear heat 
which would result in a blister. 



98 LOCAL APPLICATIONS 

Poultices may be ordered to be applied two-hourly, or four-hourly, but 
as a linseed poultice does not retain the heat longer than thirty minutes 
or an hour, according to its size, it should be removed when its heating 
power has ceased, especially il' it makes the patient uncomfortable and 
restless. 

When removing a poultice the nurse takes to the bedside some olive oil 
swabs, with which to remove any particles of linseed adherent to the skin, 
some dry wool to dry the skin and powder, and a layer of warmed cotton 
wool with which to cover the part — which is lightly bandaged on by means 
of a gauze bandage. The skin should be inspected to see if it has been un- 
duly reddened, in which case it might be necessary to smear it with olive 
oil instead of drying it. Whenever a reddened area is to be dried, it should 
be blotted dry, not rubbed. 

Mustard poultice. A linseed poultice with mustard added is described 
as a mustard poultice, but the amount of mustard to be used is generally 
ordered in a definite proportion to the linseed. When this is left to the 
nurse she may consider the proportions of \ part of mustard to 15 of lin- 
seed sufficient for a child of three, i to 10 parts for an older child, and i to 5 
for an adult. She should be careful to get her proportions accurately 
measured, but this may easily be done by ladling out say fifteen spoonfuls 
of linseed to one spoonful of mustard, as suggested in the first instance. 

Another important point is to see that the mustard is well mixed with 
the linseed so that it is uniformly distributed over the whole application. 
This may be done by rubbing the mustard into the linseed meal as fat is 
rubbed into flour in making pastry; or the necessary amount of mustard 
may be mixed to a paste with tepid water beforehand, and added to the 
hot water with which the poultice is to be mixed before the linseed meal is 
sprinkled in. 

In applying a mustard poultice the nurse must take care not to blister the 
skin. She will apply the poultice as described in the case of linseed, but 
she should not leave the bedside for long. After from 10 to 15 minutes she 
should raise the edge of the poultice and inspect the skin, where she may 
find a varying degree of erythema due to the action of the mustard. She 
should then inspect it at more frequent intervals and remove when the skin 
is well reddened — it should be a deep pink, but not angrily red. The same 
precautions should be taken as in removing a linseed poultice, but in this 
case it is always advisable to smear the skin well with oHve oil, and then to 
cover it with a piece of lint. 

Charcoal poultice. A charcoal poultice is very occasionally ordered 
for application to some offensive sore. Charcoal is deodorant and drying in 
character. It is too drying to be used undiluted, and is therefore mixed 
with linseed meal in the proportions of one part of charcoal to four or five 
parts of linseed. This poultice is meant to be an antiseptic application, and 
some antiseptic lotion, such as 1/60 or 1/80 carbolic, is accordingly used 
instead of w ater for mixing the poultice. As far as possible, asepsis is main- 
tained, and the face of the poultice is covered by a single or double layer 
of sterile gauze. 

To prepare and apply. The carbolic lotion is ready boiling in a saucepan 
on a stove or gas ring. The prepared mixture of charcoal and linseed is 
sprinkled in the boiling liquid and stirred with the spatula, great care 
being taken to see that it does not become too dry. The spatula may be 



POULTICES AND PLASTERS 99 

considered sterile. The mixture is now poured out on to a piece of sterile 
lint, smeared evenly across with the spatula and covered with the sterile 
gauze. The edges are turned over. The back of the poultice is placed on a 
piece of sterile wool and outside this lies a piece of jaconet. It is then 
applied to the sore. 

Starch poultice. A starch poultice is used to remove dried crusts, 
mainly in scabby skin conditions such as impetigo. The starch is prepared 
in a state of soft consistency and sets in a jelly round the scabs, thus soften- 
ing them. It is usual to add to the starch some very mild antiseptic, such 
as boracic acid or borax, which tends to soften the scabs. The thickness 
of the poultice must depend upon the depth of the scabs, and it may be 
any thickness from one to one and a half or two inches as required. It is 
essential for the scabs to be completely covered. 

To prepare. Starch is made as for laundry purposes — that is, some pow- 
dered starch Is mixed to a smooth paste with a little cold water, the borax 
is added, and boiling water is poured on until the desired consistency is 
obtained. As a guide to quantity, from 1 to 2 ounces of powdered starch 
and from i to 2 drachms of borax can be mixed to a smooth paste with 
from 2 to 3 drmces of cold water. This will require from i to i J pints of 
boiling water, and the size of the poultice will be sufficient to cover the 
patient’s head. 

The nurse will find that success will be attained if she attends to the 
following points — ^When pouring the boiling water from the kettle on to 
the paste of starch, she should pour the water on quickly and stir very 
slowly, until the starch begins to thicken, when she will notice that it is 
changing from a white clearness to a dirty opacity. At this point she should 
pour the water on very’ slowly and stir very rapidly; she will then notice 
that the starch appears to cook and thicken, and now very accurate 
judgement is necessaiy in order to obtain the exact consistency required. 
It is quite worth practising, and the nurse will realize that quantities given 
in textbooks are of very little value as starch varies very much. 

The mixture is next poured on to a piece of old linen and, if diis has been 
wrung out of water and is damp, the starch will adhere more closely and 
will not so readily fall off the surface of the linen when tlie poultice is lifted 
off the board. A good margin should be left, but it is not necessary to fold 
the linen over at the margins. This is a matter of choice. The mixture 
which has been poured on to the linen should be allowed to cool to a com- 
fortable temperature before it is applied. The face of the poultice may be 
covered with gauze. 

To apply. The part to which the poultice is to be applied should be 
cleaned with olive oil swabs as well as possible without causing pain. 
Olive oil or vaseline should be smeared round the edges, where the starch 
will cause discomfort by sticking to the skin when it begins to dry. The 
starch poultice may be covered either by jaconet or only by a layer of wool, 
and then bandaged in position. 

To remove a starch poultice. The nurse sliould take to the bedside some 
<>live oil, boracic swabs, dissecting forceps, receivers, and a freshly pre- 
pared poultice if the application is to be repeated — if not, some linen or 
lint which is soaked in olive oil for application to the affected area and 
some wool to cover it. 

She removes the poultice with great care, very slowly and gently, 



LOCAL APPLICATIONS 


too 

easing with the dissecting forceps any scabs that have become loose, in 
order to get as many as possible away on the poultice. She puts the poultice 
into the receiver prepared, inspects the skin and, using dissecting forceps 
and olive oil swabs, tries to detach loose particles of scab and to render 
the skin as clean as possible, gently mopping any bleeding points with the 
boracic swabs provided. 

Plasters. See also p. 96, in which the composition of a plaster is 
described. 

Mustard plaster. This substance, which is frequently used as a 
counterirritant, may be applied in the form of a mustard leaf or a mustard 
plaster — the latter is also sometimes described as a mustard poultice^ but as 
poultices usually consist of a soft mass, applied hot, the term is apt to be 
confusing. 

A mustard plaster may be prepared by mixing mustard and flour together, 
either in equal parts for a strong plaster; or using one part of mustard 
to four or six of flour when a weaker application is desired. The mustard 
and flour should be mixed together with a small quantity of water, and it 
should be free from lumps and quite smooth and of a consistency that can 
be spread with a spatula or knife. The mixture is spread on to either paper, 
gauze, linen or lint, to a thickness of about an eighth of an inch. The 
application should be made to the size that has been ordered, and it may 
be four, six or eight inches square; the surface of it should be covered with 
one or two layers of gauze — one layer is sufficient if the mesh is close — 
and, after inspection of the skin to see that it is in good condition, the 
plaster may be applied and covered with a piece of cotton wool slightly 
larger than the plaster, and lightly bandaged on. 

Mustard is a very powerful irritant. The nurse should raise the corner 
of the plaster from five to ten minutes afterwards and note the degree of 
reddening, and remove it altogether when the skin is thoroughly pink, 
picking off any bits of mustard with olive oil swabs, smearing the skin 
with olive oil, dabbing it dry and powdering it. It should be covered with 
a piece of lint or a thin layer of cotton wool as a protection to the somewhat 
painfully red, irritated surface. Mustard is never used for blistering (see 
Blisters, pp. 107-9), as it is very irritating and causes a nasty slough 
which takes a long time to heal and results in a scar. It is very important, 
therefore, that all nurses should realize that in no circumstances whatever 
should a blister be allowed to form. The application should be removed 
before the skin becomes oedematous and dark red, as this state would 
result in blistering even when the plaster had been removed. 

Mustard leaf This is a preparation of mustard ready prepared on a 
piece of paper which very often has the instructions printed on the back or 
on the envelope in which the article is supplied by the chemist. The usual 
instructions indicate that the application should be moistened by soaking 
it in tepid water for a few minutes, shaken to free the paper of moisture 
and applied to a suitable area of the skin, gently covered, held or lightly 
bandaged in position for a few minutes — not more than 20 — and subse- 
quently treated as described in the case of mustard plaster. 

Belladonna and opium plasters. These two plasters are commonly 
used for the relief of muscular rigidity, spasm and pain. It is usual for the 
doctor to state the size which is to be applied, from 4 to 6 inches square 



POULTICES AND PLASTERS 


101 


being a usual application. The plaster, after being slightly warmed by 
holding the back of it against a jug of hot water, should be pressed on to the 
skin with the hands until it adheres, care having been taken that the area 
of skin is whole and free from abrasions. It may be necessary to snip the 
edges in order to make it fit without creasing, as creases in plaster are apt 
to become uncomfortable and may lead to soreness. As a rule this type of 
plaster is left on until the edges curl up, though it may sometimes be 
ordered for a specified time. 

A belladonna plaster is occasionally applied to the breast in order to 
limit the secretion of milk when a mother has lost her baby. It is important 
to watch her carefully for any signs of belladonna poisoning. 

LINIMENTS 

Liniments are soapy, oily preparations containing drugs which are 
rubbed into the skin, usually in order to produce a local effect by stimulat- 
ing the circulation, and so effecting some degree of counterirritation or 
resulting in soothing of spasm and pain, according to the ingredients 
contained in it. 

To apply a liniment. Having arranged the patient in a position in 
which he can be relaxed and comfortable throughout the application, 
the pillows and bedclothes should be rearranged so that the part to be 
treated is easily accessible. The articles required at the bedside are a tray 
on which is placed the liniment, a gallipot into which the amount of 
liniment to be used is to be poured, and a bowl of hot water in which the 
gallipot can be placed so that the liniment will be warm before it is 
applied. A towel or two are needed to protect the bedclothes, and on one 
of these the nurse wipes the back of the hand in wliich the liniment is 
transferred from the gallipot to the patient’s skin. A pad of wool, bandage 
and safety pin should be provided for covering the area afterwards. 

Liniments in common use include: A,B,C, liniment, containing aconite, 
belladonna and chloroform, used for the relief of pain in lumbago, 
neuritis and rheumatism; camphorated oil, containing camphor, which is 
used as a mild counterirritant for application to the front and back of the 
chest in cases of laryngitis, tracheitis and bronchitis; oil of wintergreen, or 
the equivalent chemical preparation, methylsalicylate, which is specifically 
used in the treatment of rheumatism. In these three instances, and in most 
other cases except where contraindicated, the liniment is w'armed before 
use. A little is poured on to the palm of the hand, and rubbed well into 
the skin, the process being repeated for a duration of from lo to 15 minutes 
until the skin is well reddened. It is important for all nprses to realize 
that this reddening of the skin is an indispensable part of the treatment. 
The area which has been treated is then covered with warm wool, to protect 
the personal clothing from the liniment which may remain on, in order 
to keep the part as warm as possible so that more effective absorption 
occurs. 

Iodine* Preparations of iodine arc painted on to the skin either because 
of its antiseptic action, as in preparation for cutting operations, or in 
order to act as a counterirritant. 

Before applying iodine it is very important that the skin should be dry. 
Iodine is a preparation in alcohol, which readily evaporates when exposed 



102 LOCAL APPLICATIONS 

to the air. If evaporation does not take place, a blister will be caused when 
the part is covered up by personal or bedclothing, because of the retention 
of the iodine vapours. It is important, therefore, that a surface of skin 
painted with iodine should not be covered up until the nurse is sure tliat 
the skin is perfectly dry. 

Application, The articles required at the bedside are a tray on which is 
placed a bottle of iodine, a gallipot into which a small quantity can be 
poured just before it is required for use, either a camelhair brush or a 
cotton wool swab in forceps, with which to apply the iodine, and a layer 
of lint or linen to cover the part so as to prevent soiling of the patient’s 
personal clothing or bedclothes. 

The patient should be prepared as for the application of liniment. 
The bedclothing needs particular attention as iodine stains linen very 
badly. The nurse should be quite sure as to which is the area to be treated 
and the exact size of this area. A layer of iodine should be painted veiy 
evenly over the skin, allowed to dry, and the process then repeated. It is a 
good plan to apply the first layer in vertical strokes, the second in horizontal 
strokes, and so on. Application will be made until the part is either a light 
brown or a dark brown as required. A nurse might overdo this application, 
not realizing how dark a colour she will obtain until the iodine has dried, 
but if this happens it is possible to wipe off some of the iodine with swabs 
wet with alcohol. 

If the patient complains of burning after the application has been 
considered dry and covered up by the nurse, she should inspect the area 
to see what has happened. It may be that the patient has perspired and 
the skin become wet. In this case she should wipe the skin over with 
alcohol and allow it to dry before it is covered up again. 


OINTMENTS 

Ointments are preparations of fatty substances either of lanoline or lard, 
or of liquid paraffin or vaseline, containing in many cases a drug for appli- 
cation to the surface of the body. 

Ointments may be used: 

{a) To protect an abraded or raw surface, and in this case the base 
should be non-absorl)ent in character — ^liquid paraffin or vaseline. In 
addition to protecting the part, the ointment may contain some healing 
substance, such as zinc, eucalyptus or menthol, or some antiseptic sub- 
stance such as creosote or carbolic, or something with antiparasitic 
properties, such as mercury. When the ointment is to be used for cither 
of these purposes it is usually spread on lint or gauze. If the surface to 
which it is to be applied is raw or abraded, the articles used should be 
sterile. 

To spread ointment on linty the nurse should prepare an ointment slab and 
spatula or knife, and if the ointment is hard she will require a jug of hot 
water in which to heat the spatula. The ointment may be spread on the 
smooth side of lint or linen. It should be evenly and thickly spread, like 
evenly buttered bread. If the ointment is required to be applied in strips 
as in the case of Scott’s dressing (see below), it is best to spread it over a 
sheet of material first and then to cut it into strips of the desired size as in 
this way time is economized and the edges of the material arc more evenly 
covered with the ointment. When an application is to be made to the face, 



OINTMENTS IO3 

a piece of lint of the desired size is spread with ointment and a mask is 
made, by cutting holes for the eyes, nostrils and mouth. 

(6) An ointment may be used for the purpose of countcrirritation, and 
in this case it should be rubbed in vigorously. 

{c) When an ointment is used in order to convey a drug into the circu- 
lation by absorption through the skin, the treatment is carried out by 
inunction, which is described on p. 325. In this case the base used is of 
an animal fat which will be readily absorbed, such as lanoline or lard. 

When ointment is used to protect the skin round an opening made of 
some part of the alimentary tract, as in a case of gastrostomy, duodenos- 
tomy or colostomy, the nurse has to consider whether the secretion from 
the wound is likely to effect alteration in the fat used. If, for example, 
the discharge contains pancreatic fluid, this will alter the character ol 
animal fat, and in such a case, therefore, she must use some preparation 
which will not be affected, such as paraffin or vaseline. 

Scott’s dressing. This is an application of mercury— unguentum 
hydrarg. co. — containing mercury, olive oil and camphor, but although 
it is prepared in the form of an ointment its mode of application requires 
special description. 

The ointment is rather hard and should therefore be warmed before it 
is spread on the lint or linen, which should then be cut into strips of about 
I J to 2 inches wide. It is usually applied to a joint in order to reduce 
inflammation, such as may occur in chronic synovitis of the knee. The 
ointment application is covered up by strapping firmly applied, and by 
this means not only an application of mercury but at the same time an 
application of pressure is employed, which will facilitate the reduction 
of the swelling as the mercury produces its effect. 

To apply. The joint should be washed, thoroughly dried, and shaved 
if necessary. The strips of linen spread with ointment are applied from 2 
or 3 inches below the joint to 2 or 3 inches above it. The first strip is 
applied well below, and is crossed on the outer aspect of the joint; the sec- 
ond and subsequent strips overlap each preceding strip by half an inch 
and are carried up to above the knee. Strips of strapping slightly wider 
than the strips of linen are then applied in the same way, beginning on the 
skin half an inch below the first layer of linen and continuing over the 
joint to half an inch above the top layer. The strapping is applied firmly 
and each layer is crossed, over the outer aspect of the joint, so that the 
crossings lie directly one above the other and form an even pattern (see 
fig. no, p. 238). This application will require to be removed every 
week. The indication for renewing it will be that it becomes loose as the 
inflammatory condition of the joint lessens, the swelling decreases and the 
joint becomes reduced in size. Before making a fresh application the nurse 
should wash the area thoroughly with hot water and soap and remove 
all stale ointment. 

The strapping should be covered by a firm bandage as the mercurial 
ointment is black and may stain the patient’s personal clothing. More- 
over, there is less danger that the strapping may become curled up at the 
edges if it is kept in position by means of a bandage. 

Scott’s dressing contains 1 2 per cent, of mercury, and the nurse should 
therefore know the symptoms of mercurial poisoning and be able to 
recognize any early symptoms that may show themselves. It is advisable 



1 04 LOCAL APPLICATIONS 

when caring for such patients as are submitted to this treatment to make 
careful inquiries regarding their appetite, as one of the earliest symptoms 
of mercurial poisoning is nausea, loss of appetite and a nasty taste in the 
mouth. 

APPLICATION OF WAX, UNNA^S PASTE AND GLYCERINE 

PREPARATIONS 

Wax. Either parc^n wax or amhrine wax, which is a proprietary pre- 
paration, may be used as a dressing for inflamed and raw surfaces. In 
addition, ambrine wax is used for the relief of many painful conditions. 

Method of application. In the case of paraffin wax, it should be heated to 
130"^ F., while ambrine wax may be heated to 140° or 150"^ F. To apply 
ambrine wax to an inflamed area in which there are some raw surfaces, 
the wax should be heated and kept standing in a container of very hot 
water so that it does not lose heat. Forceps and wool swabs will be re- 
quired wdth which to apply the wax, and flakes of cotton wool to cover it, 
and these will be secured in position by a bandage. 

Saline solution and sw’abs should be supplied with which to wash the 
area, and sterile towels to dry it thoroughly. It is a very important part 
of the preparation that the skin should be thoroughly dry, as wax will not 
adhere to a moist surface, but instead, will be seen to rise from it in blisters. 

The area having been cleansed and dried, the wax will be painted on 
to the skin, in an even layer, the nurse having first tested the temperature 
on the skin at the flexure of her elbow, with a swab of w^ool. Having 
applied the first layer smoothly on the skin, it is covered with wisps of 
wool, the edges of each layer of wool being fastened on to the wax beneath 
by use of a swab dipped in the hot melted wax. When the dressing is 
sufficiently firm, a layer of cotton wool is placed over it and this is 
bandaged on. 

When properly applied the wax will be seen to be closely adherent to 
the skin so that, when the dressing is changed, it has to be detached. It 
peels off readily, since the wax is of a soft, pliant nature. 

A wax dressing is valuable for all superficial inflammatory lesions, and 
also for bums of the first, second and third degrees. When used for either 
of these purposes it is usual to change the dressing after 24 hours — the 
second dressing can be left on for several days. 

Unna’s paste. This is a soothing preparation containing zinc oxide, 
glycerine, gelatine and water. It is used in the treatment of dry eczema 
and for many irritable skin conditions. It is also specially valuable in the 
treatment of chronic ulcers, including varicose ulcers. 

Application, The paste is melted in a glucpot, or by placing it in a saucer 
pan of hot water on a gas ring. The part to which it is applied must first 
be thoroughly cleansed, and as far as possible crusts and scabs should be 
picked off; if the skin is hairy it should be shaved. The melted paste is then 
applied, with a broad, camel-hair brush, to a thickness corresponding to 
that of a rubber glove, so that a pliable covering is made on the skin. 
This first layer is either covered by a layer of gauze, or wisps of wool may 
be used as described in the application of wax. Further layers of paste are 
painted over this, and the process is repeated until the dressing is of the 
desired thickness. This application does not need covering with an outer 
layer of wool, as it forms a firm and gelatinous casing — any superfluous 



APPLICATION OF WAX IO5 

wool on the surface can be picked off, and a bandage carried over the paste 
to protect it. 

A Unna’s paste dressing can be left on for a week or ten days, when it 
will require to be changed — ^if a second dresssing is employed it may be left 
on for two or three weeks. In the treatment of varicose veins an application of 
Unna’s paste is sometimes made in conjunction with the application of an 
elastoplast bandage. This is also a proprietary preparation, the bandages 
have a certain degree of elasticity and when applied fairly tightly give 
considerable pressure which tends to improve the circulation of the 
limb. 

Glycerines, The preparations of glycerine most commonly used are 
glycerine of borax ^ used in cleaning the mouth; glycerine of belladonna^ which 
is used to relieve pain in neuritis and rheumatism, phlebitis and throm- 
bosis — it also lessens secretion and therefore assists in the termination of 
inflammation by resolution which is aimed at in the treatment of throm- 
bosis; glycerine of ichthyol is an antiseptic substance which smells rather like 
tar and is prepared from fossilized fish — it is a very valuable local appli- 
cation for the relief of inflammation, and is particularly useful in the 
inflammation following severe sunburn, mosquito and bug bites. It is used 
for the treatment of the inflammation which occurs in erysipelas, and also 
as a local vaginal application in cases of chronic discharge. 

Both belladonna and ichthyol are dark in colour, and being glycerine 
preparations become absorbed by lint, wool and bandage used as cover- 
ings, so that care must also be taken to avoid staining of the patient’s 
personal or bed clothing. 


APPLICATION OF LEECHES 

Leeches are bloodsucking parasites which are used to relieve conges- 
tion and pain, particularly in eye surgery. They are also used to relieve 
cyanosis, when applied to the chest in cases of cardiac congestion, and in 
the same situation for the relief of pain in pneumonia. 

The articles required, in addition to the number of leeches, will be 
several test tubes threequarters filled with cotton wool — each leech will 
be collected in a tube, tail end in, and by this means will be applied to the 
patient’s skin. Some warm water is needed in order to prepare the skin. 
Soap and antiseptics may not be used. The object is to render the skin 
slightly red and moist to attract the leech, and for this reason also the skin 
should not be dried. A leech likes a moist surface, and is used to attacking 
its prey under water. 

A piece of lint or linen with a tiny hole cut in the centre will be required, 
through which the leech will be allowed to bite the patient. The body of 
the leech may be allowed to remain in the test tube, or the tube may be 
withdrawn and then the leech will be on the piece of lint — the slimy 
parasites should never be allowed in contact with the patient's skin. 

A bowl of I /i20 carbolic is provided in which to place the leech when it 
falls off, and this solution will destroy the leech which can then be put 
down the sluice. 

Pads arc needed to form a pressure dressing in case the leech bite bleeds 
more than is desired, and these may be made of rounds of lint, increasing 
in size from small to large ones. Strips of lint can be arranged starwise 



I06 LOCAL APPLICATIONS 

over the bite and, as all the strips will cross over the point of the bite, 
the greatest pressure will be applied here (this method is illustrated in 
fig. 38, p. 158); or two rolls of lint may be used, one across the other. 
Whatever form of pressure dressing is employed, it must be either strapped 
or bandaged in position. 

A fomentation may be employed if it is considered necessary to en- 
courage the bleeding to continue. 

To apply. If possible explain to the patient what is going to be done, 
but do not let him see the leeches. Having prepared the skin and left it 
damp, place the piece of lint with the hole in the centre over the part to be 
treated; collect the leech in a test tube and render the lint taut upon the 
skin, so that the leech does not get away beneath the lint, but bites exactly 
where the hole lies. When the leech is holding well, the test tube may be 
gently withdrawn and the leech then rests lightly on the lint. 

If a leech refuses to bite, the skin may be pricked with a sterilized needle 
to withdraw a tiny drop of blood. This method Ls better than applying 
milk, as the latter may not be sterile. 

A leech should never be pulled off or its teeth will be left in the wound 
and may give rise to sepsis. If there is any reason for removing it before it 
has had its fill and is ready to fall off, a sprinkle of dry salt on its head will 
render it thoroughly uncomfortable, and it will loose its hold. 

A leech draws a very small quantity of blood, and the amount with- 
drawn is useful enough when taken, say, from near the eye; but when 
leeches are applied to the chest it is usual to follow their removal by 
fomentations in order to extract more blood, and thus as much as half a 
pint of blood may be removed. 

If the leech bite continues to bleed, it may be necessary to use a pressure 
dressing which has been prc\’iously described. As the leech feeds, it 
secretes a substance called hirudin from glands in the region of its head 
which prevents clotting of the blood it sucks into its stomach. Some of this 
substance gets into the patient’s tissues and prevents clotting there. It is 
because of this that bleeding may continue. 

A leech bite always leaves a tiny white triangular scar like a bird’s foot- 
mark, which persists for a long time, and such scars are sometimes observed 
on patients admitted to hospital. 

COUNTERIRRITANTS 

A counterirritant is a means of producing superficial irritation or in- 
flammation with the object of relieving a symptom arising in the deeper 
tissues — such as pain — or with the object, by bringing blood to the surface, 
of relieving a more deeply seated congestion. Counterirritants act thus 
by producing a condition of hyperaemia, and by this means they alter 
the blood supply of the part to which they are applied; alternatively, 
their effect may be produced by reflex stimulation of an organ which may 
be associated with the area of skin to which the application is made. 

Counterirritants arc classified according to the effects they produce. 

Rubefacients are those which cause reddening of the skin. Many of the 
applications already described, all applications of heat — ^including those 
to which some irritating substance has been added — turpentine and 
mustard act as counteriritants. Any means which produces hyperaemia 



COUNTERIRRITANTS 1 07 

can be included, such as the brisk rubbing of a part, as for example when 
a liniment is rubbed in, and if the liniment should contain a substance 
stimulating to the circulation, such as camphor or turpentine, the effect is 
enhanced. 

Painting the skin with different chemicals, such as the iodine painting 
already described, and the application of various irritating substances 
such as a mustard plasters are other means of reddening the skin and so 
producing a form of counterirritation. 

Vesicants. The degree of counterirritation, next in severity to redden- 
ing, is the production of a blister. An agent is chosen which produces a 
fairly clean blister, only raising the epidermis and leaving a comparatively 
well-stimulated raw area beneath, which will heal fairly rapidly without 
sloughing or scarring. Cantharides is the substance mainly used for this 
purpose, and it is prepared from a blistering fly prevalent in South America 
and Spain. It is supplied in the form of plaster, ointment and fluid — 
liquor epispasticus — and as collodion — collodion vesicans. Probably the most 
convenient form for ready application is the prepared plaster, made up 
on strong linen which has a green back, and is marked out in inch squares 
very conveniently for cutting up, since the majority of blisters arc ordered 
to be either half an inch or an inch square. The active side of the plaster 
is blackish grey colour and slightly tacky in consistence. 

In all cases, the area of skin which is to be blistered must be aseptically 
prepared; therefore, in whatever form the blistering agent is used, the 
nurse must also take to the bedside the articles needed for cleaning the 
skin and for covering the blister. The articles required include materials 
for cleansing the skin, a blistering agent which which may be fluid, 
ointment, or specially prepared plaster. If blistering fluid or ointment is 
employed a sterilized glass rod should be supplied with which to rub the 
blistering agent into the skin. 

To apply blistering plaster. Having prepared the skin, and cut the plaster 
to the size ordered, if cut square the corners should be snipped off as this 
will provide a round blister rather than a square one, and the blistered 
area will heal the more readily from not having angular corners into 
which fluid might collect and so delay the process of healing. The blistering 
plaster is applied to the prepared skin and pressed firmly on to it. It is a 
slight advantage to warm the blistering plaster beforehand, by holding 
its back against a jug containing hot water. 

When applied, the plaster may be covered by a layer of gauze or wool 
which should be very lightly bandaged on, in order not to cause pressure 
on the blister as it rises. A rather more scientific method of covering is 
arranged as follows: Take a piece of guttapercha tissue 4 inches larger 
than the blistering plaster used. Fold a pleat into it vertically up the 
middle, and horizontally across the piece of tissue (as shown in illustration, 
fig. 39, p. 158, see letter D). This is placed over the plaster and retained in 
contact with the skin by the application of small strips of strapping, as 
shown in the illustration. 

As the blister rises, the pleat which lies over the plaster gradually un- 
folds, and this has two advantages — (i) the progress of the rising blister 
can be observed, andJ(2)4therejs"no pressure upon it which would give 
rise to pain. 

The application of blistering ointmenL Having cleaned the skin, the area to 



LOCAL APPLICATIONS 


io8 

be blistered should be outlined with an oily substance — either olive oil 
or vaseline — evenly applied in the form of a circle by means of a dressed 
glass rod or tiny camelhair brush. A probe or glass rod is then dressed 
with cotton wool, covered with the blistering ointment and rubbed 
vigorously over the part to be treated. The rubbing should be continued 
for a few minutes until the area is well reddened. 

Blistering fluid. The application is made in much the same way as des- 
cribed above for the application of ointment. A point to be remembered 
in this case is that one layer of fluid will not blister a fairly tough skin, 
and it will certainly not produce a blister on a part that has been previously 
treated. Blistering fluid requires to be thoroughly well rubbed into the 
area treated. 

Collodion vesicans. This is a special form of collodion which contains a 
blistering agent. To apply it, the skin is prepared, and the area may or 
may not be marked out with oil as described above — this depends upon the 
proficiency of the nurse who is to make the application. The collodion is 
painted on to the prepared area. This application need not be covered, 
unless the patient is restless, in which case it will be advisable lest the 
collodion be rul)bed off. When this blister rises the layer of collodion 
will be seen adherent to the risen skin. 

To help a blister to rise, A cantharides application should result in 
blistering within 6 to 8 hours, and in some cases the blister may rise 
much earlier than this. If the application does not produce a blister 
within this time, it may be that the material used was stale and had lost 
its potency; or it may be that the patient has a particularly tough skin — 
in either case it would be advisable to apply heat over the blister. An 
application of dry heat such as a hot water bag may be sufficient, or 
fomentations or poultices may be needed. If this is not effective, it would 
be advisable to get some fresh material for the blister, and to pay very" 
great attention to reddening the skin when applying it, in order to create 
a good hyperaemia before the blistering agent is applied. 

To dress a blister. When a blister has risen the nurse should take to the 
bedside the following articles: Sterile diSvSecting forceps and scissors, with 
which to snip the blister and so evacuate the fluid and, if desirable, re- 
move the dead epidermis. Some dry absorbent wool swabs, with which 
to catch the fluid as it runs out of the blister. If this fluid is allowed to run 
over the adjacent skin, seeing that it contains blistering agent, it may 
cause irritation. 

A dressing suitable for the raw area is also supplied, and this may be 
zinc or any other healing ointment, .spread on lint, or alternatively gauze 
soaked in liquid paraffin and flavine may be used. The dressing applied 
should be the e;fact size of the blistered area, and should be kept in 
position by some means which will not retain fluid, but will permit of 
evaporation. Any serum exuding from this raw area will contain blistering 
agent and, if it is confined, may continue to injure the tissues beyond the 
effect which was intended by the original application. 

To retain the dressing in position. Strips of strapping may be used to retain 
the dressing in position, and these may be applied all round the margins 
of it, or in the form of a ‘gate’ (see p. 158, fig. 39, letter E). 

To cut a gate of strappings take a piece, at least double or treble the size 
of the blistered area, fold it and cut strips out, so that the strapping is 
similar to a three, four or five-barred gate in appearance. By this means 



COUNTERIRRITANTS I OQ 

the dressing is kept adherent all round its edges and has one or two strips 
of strapping across it, and yet it permits air to reach the dressing, so that 
evaporation readily takes place. 

The dressing will require changing twice a day at first and then once a 
day. Healing takes place fairly rapidly. 

A flying blister. By this is meant that a blistering agent is applied for a 
short time, long enough only to redden the skin, and a number of these 
applications are made round a given area. 

Cantharides is one of the drugs which are irritants to the kidneys. It is 
therefore important to test the urine for albumin for a day or two after 
its application, for fear lest any untoward effects have been caused. The 
administration of liberal bland fluids will, by stimulating urinary secretion, 
tend to prevent any irritation. 


CUPPING 

Cupping is a form of coiinterirritation by which the dilatation of the 
subcutaneous blood vessels is effected. Heated glass cups are used and a 
partial vacuum created; the prepared cup or glass is applied to the area 
to be treated, and consequently the superficial tissues arc attracted into it 
to fill the partial vacuum, thus bringing a good deal of blood to the sur- 
face. Some special cupping glasses, described as Bier's or Klapp^s suction cups^ 
have rubber bulbs attached, by means of which the vacuum can be 
created after the glass object has been inverted on to the skin, thus 
obviating the trouble of heating the glasses. 

Conditions in which cupping may be ordered are inflammatory con- 
ditions of the chest such as bronchitis and pleurisy in which case one to 
two dozen cups will be applied over the chest wall. An application is 
made over the loins for the relief of renal congestion in acute nephritis. 
Cupping is one of the most comfortable forms of treatment used in 
lumbago, since it results in the relief of rigidity and pain more rapidly 
than does any other form of treatment. 

Application of dry cupping. It docs not matter very much in what 
way the vacuum is created, A nurse who is experienced can manage this 
by using a flaming torch with which to heat the glasses. The following 
is quite a useful way for nurses to practise using this application, and it is 
also quite effective and has the additional advantage that it is unlikely 
that the patient will be burnt by this method. 

The articles required (sec fig. 40, p. 159) are cupping glasses, a little 
methylated spirit in a bowl, a pair of dissecting forceps, some small squares 
of blotting paper, and either a box of matches or a lighted flame. Veiselinc 
and swabs, with which to smear the edges of the glass in order to make it 
adhere more closely to the skin, should also be provided. 

Method. Holding the cup upright in her hand, the nurse drops part of 
the blotting paper into the methylated spirit, lifts it out by means of the 
dissecting forceps, and lights it in the flame; she then drops the morsel of 
lighted paper into the cup she is holding and, before the blotting paper 
has burnt out, inverts the cup on to the area of skin she wished to treat. 
She will notice that the cup adheres closely, and that the tissues rise into 
the partial vacuum created. The process is repeated until sufficient cups 
have been applied. They should not be placed too closely together. The 



no LOCAL APPLICATIONS 

nurse should watch the skin under the cups very carefully; it will soon 
become pink, and eventually be a deep bluish red. The cups should be 
removed before any mottling occurs, and before petechial points of 
haemorrhage appear on the skin. 

To remove a cup. The cups are usually allowed to remain on for some to 
to 20 minutes. To remove, steady with one hand placed on the cup ready 
to lift it off as air is allowed to enter beneath it. The nurse inserts her 
thumbnail under the edge of the cup, and will hear the noise made by the 
rapid entry of air, and as the cup is loosened it is lifted carefully off. The 
cupped area will be very sore and tender and should, therefore, be covered 
by warm wool which may be lightly bandaged on, pressure being avoided. 

When a second application is made it is advisable to avoid putting the 
cups in exactly the same position— the rim should not rest on the same 
spot as before. 

Wet cupping. This treatment consists in the withdrawal of blood by 
incisions made in the skin before the cupping glasses are applied. The 
vacuum thus created results in drawing blood into the cu})s, but it is a 
means of bloodletting which is rarely employed today. If the nurse is 
ordered to prepare the ai ticles she will require materials to render the 
skin surgically clean, and sharp knives for making the small incisions. 
The cupping glasses should be sterile. 

The forms of bloodletting used today are venesection, and for small 
quantities the application of leeches. 



Chapter 8 

General Applications 

Applications of heat — Hot packs, vapour and hot air baths — Radiant heat baths, 
hot baths and hot sponging — Warm baths and medicated baths — Aerated and foam 
baths — General treatments for the reduction of temperature — Tepid and cold 
sponging, exposed sponging — BrandCs bath — Ice cradling — Affusion 

HOT PACKS ; VAPOUR ; HOT AIR AND MEDICATED AND 
AERATED BATHS 

B y a general application of heat the heat of the body is increased, 
loss of heat is prevented and perspiration is induced. As a result 
of increased activity of the sweat glands, the rate of the elimination 
of fluid Ls promoted. In this way the work of the kidneys is relieved, and 
this form of treatment is therefore especially useful in cases of renal 
failure in which symptoms of suppression occur. 

The immediate result of a hot application is to stimulate the nei've 
endings in the skin and, as this increases the activity of the central nervous 
system, the pulse rate also is increased. In certain cases some degree of 
congestion of the internal organs, particularly of the brain, occurs, and it 
is to prevent the discomforts associated with this — such as headache and 
throbbing of the veins of the head — that a cold compress is applied to the 
head during the administration of any general application of heat. 

A little later on in the treatment the stimulating effect is followed by 
relaxation; and during this time the patient feels drowsy and comfortable; 
but the vital organs, previously stimulated, share in this depression, and it 
is for this reason that careful watch is kept on the pulse throughout the 
administration, so that any untoward degree of depression can be 
anticipated, the treatment discontinued and first aid measures— including 
rest and stimulants — applied before any serious symptoms can arise. 

Hot applications may be either dry or moist. Dry applications may be 
made by means of convection or radiation, the former being most com- 
fortable and elSective since radiant heat tends to act as an irritant. Some 
consider moist applications better and more comfortable and more effect- 
tive than dry ones, but this is a matter of controversy. 

Generally speaking it may be said that the hot applications requiring 
the least disturbance of the patient arc to be preferred — that vapour and 
hot air baths, for instance, are preferable to hot wet packs. 

HOT WET PACK 

The articles required for a hot wet pack (see fig. 42, p. 1 60) are a long bed 
mackintosh which, covered by a dry blanket is placed beneath the patient 
to protect the matticss. 

A second dry blanket is placed over him, and he lies stripped of his 
personal clothing between these blankets. 

Two thin old blankets are required for the wet pack, and a large wringer, 
if p)Ossible, with sticks at each end for wringing. The blankets folded in the 



I 12 


GENERAL APPLICATIONS 


wringer may be placed in a sink or small bath. It has been found by 
experience that if water of i8o° to 200° F. is poured over the pack in the 
bath, by thejtime the articles are soaked through and wrung out the appli- 
cation is a little less than 120®, which is about the required temperature. 

A cold application — either a compress or icebag — ^should be provided 
for the head. Hot drinks will be administered to the patient during the 
treatment. A urinal should be ready at hand as patients, even those 
suffering from nephritis, are often stimulated to pass urine during this 
treatment, and this is possibly the result of some reflex stimulation of the 
kidneys occuring as the result of the general application of heat to the skin. 

Several dr\^ blankets and some hot water bottles which may be placed 
round the patient after he is enclosed in the pack should be provided, but the 
hot water bottles must be placed outside the hot dry blankets, and not near 
the damp blankets, as in the latter case steam would rise from the damp 
material and scald the patient. 

To prepare the pack. The blankets should be folded lengthways in 
three and then doubled over from top to bottom. If this method is used 
the blanket, when it is lifted out of the wringer, can be conveniently shaken 
and unfolded without undue exposure or cooling. 

The blankets arc laid on the wringer and the ends slightly twisted 
before it is put in the bath. It is then placed in the bath or in the sink, 
and the water is poured over. To wring it out, one nurse takes hold of each 
end of the wringer — or stick, if sticks are used — and each twists in an 
opposite direction to the other, pulling in the long direction at the same 
time, and so rendering the blanket not only twisted but taut, which helps 
to expel the water. It is wrung as dry as possible, and may be carried to the 
bedside in the wringer; or the blankets may be shaken free from steam in 
the bathroom and carried to the bedside in a warm bowl. 

To apply the pack. At the bedside one blanket is taken out of the 
wringer, shaken until it is free of steam and placed lengthways beside the 
patient's body as he lies on the bed. He is then slightly turned whilst 
the blanket is unrolled beneath him and he is placed gently upon it. The 
second blanket is placed over the front of the patient s body beneath the 
dry blanket under which he lies. The moist blankets are then tucked well 
round the sides of the body, into the axillae, round each leg, and the hot 
wet pack is covered by two or three hot, dry blankets, outside of which 
the hot water bottles may be placed as described. The cold compress is 
applied to the patient's head. The quilt may be put on, if desired, as it 
renders the bed less unsightly. 

The duration of the treatment is from 20 to 30 minutes. The patient must 
be carefully observed for changes in colour, any signs of apparent distress, 
and for the presence of perspiration on his face, which would indicate that 
the treatment was being effective. The nurse standing by should wipe the 
perspiration from his face as it is apt to be very distressing to him, but she 
must be able to report to what extent he has perspired. Observation is 
made of the pulse at the temple — any weakness of irregularity might 
indicate the necessity for stopping the treatment. The patient should be 
given hot drinks throughout. If he complains of discomfort as the result 
of these, cool drinks may be given. The most important thing is to get 
fluid into the patient, except in cases where it may be contraindicated, as 
in oedema when the fluid intake would probably be restricted. 



HOT WET PACK I I 3 

At the termination of the treatment the wet blankets should be 
gently taken away and the patient left lying undisturbed under hot dry 
blankets, lightly packed round him, and with several hot water bottles 
in the bed, so that he may go on perspiring for an hour or so. At the end 
of this time his body is sponged with hot water, his back attended to, his 
toilet completed, his personal clothing put on and his bed remade as a 
blanket bed, that is, a blanket is placed beneath the drawsheet and a 
blanket is left next to the patient. A hot water bottle may be left at his feet 
if desired. 

HOT DRY PACK 

The patient is wrapped in hot dry blankets, surrounded by hot water 
bottles and, is given mild diaphoretics such as spirit of nitrous ether, or 
hot lemon drinks. In some cases pilocarpine is ordered. 

A hot dry pack is probably most often used as a simple nursing measure 
in the treatment of the early stages of a common cold, at the onset of 
influenza, or after a very severe wetting in order to prevent chilling. In 
this case it is usually preceded by a hot bath. In hospital practice a hot 
dry pack is used in certain cases of suppression of urine, when pilocarpine 
which is a very powerful diaphoretic drug, is ordered. The patient is put 
into the pack before the drug, which is administered by hypodermic 
injection, is given, as it acts very quickly. 

The requisites include several hot, dry blankets, hot water bottles, 
warm flannel bedgown and bedsocks, and a cold compress for application 
to the patient’s head. Hot drinks should be administered throughout 
the treatment unless contraindicated. Warm, dry towels, dry blankets 
and a dry flannel bedgown are required for use at the termination of 
treatment. 

Method of procedure. The patient lies in his flannel bedgown 
between blankets, which are closely packed round him. The hot water 
bottles are placed outside these blanJkets and only his head is left exposed. 
A screen may be placed at the top of the bed to exclude draughts, or his 
head may be protected by a shawl or small blanket arranged in the fashion 
of a cowl. 

If pilocarpine is administered^ hot drinks should be given ten minutes after- 
wards in order to aid diaphoresis. Pilocarpine being also a silagoguc, the 
nurse should have at hand a small basin to catch the saliva which will 
run from the mouth. In some cases half a pint of saliva will be collected 
after the administration of pilocarpine. This is rather uncomfortable for 
the patient, but it is a valuable way of getting rid of fluid and the patient 
should be encouraged to let it flow into the basin rather than swallow it. 
The dose of pilocarpine is from i/ioth to x /6th of a grain. 

Pilocarpine is a heart depressant, and the pulse should therefore be very 
carefully watched after its administration. It also causes contraction of the 
pupU of the eye; if marked myosis occurs, and is accompanied by any com- 
plaint of pain in the eyeball, the matter should be immediately reported 
as the administration of an antidote — atropine — might be called for. 

The patient remains in the hot pack as long as he continues to perspire 
— in many cases for as long as from one and a half to two hours. His skin 
is then sponged with hot water in order to remove the excretion lying on it, 
or his body may be rubbed down with soft dry towels. His dry, warm, 
llannel bedgown is put on and he lies between dry blankets, the hot water 



GENERAL APPLICATIONS 


I 14 

botdes being refilled. Note should be made of the amount of urine passed 
during the treatment. 

VAPOUR BATH 

A vapour bath is an application of water vapour to the body which is 
made in order to increase tlxe activity of the skin. AllerCs apparatus is com- 
monly used (see illustration fig. 43, p. 161), consisting of a kettle boiling on 
a gas ring or spirit stove, or an electric kettle may be used. The steam is con- 
veyed into the bed by means of a metal chimney pipe which is attached to 
the lower one of the wicker cradles placed on the bed over the patient’s 
body. The steam is kept in the bed by blankets and mackintoshes specially 
arranged over and around the cradles. These are carefully tucked in at the 
bottom, round the communication of the chimney flue and the cradle, 
and at the sides, and are carried from the cradle at the top end of the bed 
up over the patient’s shoulders, so that as he lies beneath the cradles he is 
in a hot steamy atmosphere, (In the illustration on p. 16 1, the bedclothes 
are folded back to show position of cradles and thermometer.) 

The articles required. If Allen's apparatus is used the kettle should 
be filled with boiling water, and the apparatus placed on a stand of con- 
venient height at the foot of the bed. The chimney pipe which is rec- 
tangular in shape runs from the kettle to the wicker cradle at the foot of 
the bed, to which it is attached by means of a metal spreader hung on to 
the open end of the lower cradle. Two or three low wicker bedcradles 
extend from the patient’s shoulders to the foot of the bed. A bath ther- 
mometer is hung from the lower end of the upper of the three cradles, 
where it can be conveniently seen. Several warm blankets and three long 
bed mackintoshes, which also must be warmed, should be supplied, and a 
small blanket to cover the patient’s feet. 

A bucket of sand should be at hand in case of fire if a spirit lamp or gas 
is used. There will also be needed a face towel, so that perspiration can 
continually be wiped off the patient’s face; a cold compress or an icebag 
for application to the head; a warm drink ready prepared in a feeder, 
from which the patient can drink when lying dowm; a stimulant and 
oxygen to be at hand in case of collapse — ^although this is extremely rare, 
and with good nursing care the need for their use should not arise. Hot 
towels, hot blankets and hot water bottles should be in readiness for the 
termination of the treatment. (See fig. 43, p. 161). 

Method. The patient is placed lying in bed, a warm blanket is laid over 
him, and his personal clothing is removed. A warm blanket should cover 
the mackintosh which is placed beneath him; his feet are wrapped in a 
small blanket specially provided, the cradles are placed over him as he lies 
covered by a warm blanket, and the bath thermometer is placed in position. 

The bedclothes which are to be arranged over the cradles should be 
placed in the form in which a divided bed is made (see p. 79) . The division 
should come at the junction of the upper and middle cradles, and the bed- 
clothing should overlap at least eight inches so that there is no possibility 
of escape of vapour. 

The spirit lamp or gas jet is lit, when the water boib, steam is passed 
into the bed. When the temperature reaches 105® F. or a little over, the 
nurse should draw the blanket which is covering the patient's body away, 
so that his skin is exposed to the warm water vapour. This naay be carried 
out by manipulation of the bedclothes where they overlap at the centre, 



VAPOUR BATH 


II5 

the nurse putting her arm in and uncovering the patient’s body, leaving 
the blanket at his side presssed up against the wicker cradles; or she might 
carefully remove it, drawring it out, in the slit provided, being careful 
iTicanwhile to see that she does not allow the bed to get cool. 

As soon as the bed begins to get fairly warm — that is, when the tem- 
perature is about 1 10° to 1 15° — a cold compress should be applied to the 
patient’s head and renewed as often as necessary. One nurse remains by 
the patient’s bedside throughout the treatment, and it is her duty to note 
the rate at which the temperature of the bed rises, and to watch its effect 
on the patient; when it has reached 120^ to 125°, she should readjust the 
supply of heat in order to retain the temperature of the bed at this level 
for from 15 to 20 minutes. 

She also carefully watches the patient for any signs of distress — for a 
change of colour in liis face or for the presence of perspiration over his 
forehead and lips, which she should carefully wipe off with the face towel 
provided. She keeps his mouth moist and gives him a drink from time to 
time. In case of any sign of distress or collapse, the treatment should be 
immediately suspended and the restoratives which have been provided 
should be administered. 

At the termination of the treatment, which should last from 15 to 
30 minutes, the light is first extinguished or the electricity turned off, and 
the apparatus is taken aw^ay from the foot of the bed. The nurse should 
continue to stand by the patient and make observations as before. In 
about half an hour the bed will have cooled slightly; she may then untuck 
the bedclothes, remove the mackintoshes from over the cradles and draw 
the cradles gently out, letting the hot dry blankets fall and lie on the 
patient’s body. Hot water bottles may be added, one being placed in 
the vicinity of the feet, and others on either side of the patient’s body, and 
the patient being allowed to lie under these blankets for an hour or more, 
during which time he will go on pei'spiring if his skin is left undisturbed. 
At the end of this period his body should be sponged with hot water in 
order to remove sweat. Clean flannel clothing is put on and the bed made 
up in the fonn of a blanket bed. Throughout the whole treatment similar 
observations are made on his condition, and the nurse should be prepared 
to report on the amount the patient has perspired; whether he has per- 
.s|)ired well, moderately, or only slightly; the length of time he continued 
to perspire after the treatment was terminated, and the amount of urine 
he passed during and after the treatment. She should also make general 
ol )servations of the condition of the patient, his pulse and colour and his 
Kcrieral appearance of comfort or otherwise, and w^hether he slept after 
the treatment. His temperature, pulse and respiration might be taken both 
before and after, although this is not absolutely essential as careful 
observation of the pulse throughout is of primary importance. 

HOT AIR BATH 

The same apparatus is supplied, but omitting the kettle of water as 
described in the administration of a vapour bath, and very similar pre- 
cautious are necessary. Air, not vapour, is passed into the bed; the air 
heated by the flame beneath the graduated funnel rises, and is carried 
into the bed by convection. In this way dry, hot, moving air is constantly 
supplied over the patient’s skin. He feck no discomfort from this as. 



GENERAL APPLICATIONS 


I l6 

owing to convection, evaporation of moisture from the surface of the body 
is materially assisted. 

The following points are of considerable importance, and must be 
carefully attended to: 

( 1 ) The heat of the bed must be very gradually raised, and it should 
take at least twenty minutes for the temperature to reach 140° F, — the 
average degree of heat employed when hot air is introduced. The mean 
range is from 120'' to 180° F. For a first treatment it may be found im- 
possible to proceed above 120° — much depends on the extent to which 
the skin is active. The treatment should be terminated if the skin does not 
act, as in this event the patient is merely being made uncomfortable, his 
temperature is rising and the treatment is being harmful rather than 
beneficial to him. Nurses must realize the importance of this point and 
make accurate and careful observation of the state of the patient’s skin. 

(2) As the body is losing heat by evaporation of moisture induced by 
convection, another point of importance is that no two skin surfaces 
should be permitted to lie together, as this would prevent evaporation; 
the lower limbs should therefore be slightly separated and the arms should 
lie on each side of, but away from, the sides of the body. 

WARM BATHS AND MEDICATED BATHS 

Warm baths at a temperature of 95"^ to 100° F. arc used for a variety 
of conditions. Possibly their most important use is in the treatment of 
insomnia, when lying in warm water soothes the circulation generally 
and results in relaxation of muscle and a reduction of the activity of the 
brain, so probably inducing sleep. When a warm bath is continued for 
longer than a hour and a half to two hours at a time, it is described as a 
continuous bath. 

For the administration of a continuous warm bath^ some means must be 
secured to keep the water at a constant temperature, and there must 
therefore be an outlet for cool and an inlet for warm water. The patient 
should be made comfortable or he will suffer from cramp and fatigue. 
He should be suspended in a hammock as he lies in the water, with his 
buttocks resting on a ring air cushion; air pillows might be arranged to 
support his back, and his head and neck should rest on a specially de- 
vised horseshoe-shaped air cushion. It is always advisable to provide a 
footrest, or otherwise he is liable to slip down the bath. The bath should 
be covered and only his head exposed above the covering. The room should 
be quiet and gently lighted so that irritating stimuli are absent. It is 
inadvisable to leave a patient lying in a bath, and a nurse should there- 
fore be in attendance. 

Warm baths are also used in the treatment of many cases of skin disease, 
particularly at the outset of the treatment when it is necessary to remove 
crusts and scabs. For this purpose some antiseptic may be added to the 
water. 

Emollient baths are used in cases of skin irritation, the substances 
frequently employed including powdered borax^ \ pound to 30 gallons — 
brariy 2 to 3 pounds — linseed or oatmeal^ i to 2 pounds. Bran, linseed and 
oatmeal should be added to the water by being tied up in a strong bag 
and boiled in a large saucepan containing half a gallon of water — ^thc 
mucilage so obtained is then added to the bath. Slar ^ — i pound of starch 



WARM BATHS AND MEDICATED BATHS I I 7 

mixed to a paste with cold water, made into a mucilage by pouring on 
boiling water, is added to the bath. Glycerine — lo ounces to a bath. 

Antiseptic baths, used for the relief of parasitic skin conditions, in- 
clude sulphury 2 to 3 ounces to a hdith— creosote y i to 2 drachms* — carbolicy 
of the strength of 1/300 may be used. This requires a little calculation, 
but if the bath is of the capacity of 30 gallons, 16 ounces of pure carbolic 
thoroughly mbced in five pints of boiling water and added to the bath 
will be found to give the correct quantities. Iodine — i ounce of tincture of 
iodine is added. Mercury, a dilution of i /8,ooo is the usual strength ordered. 
This can be attained by dissolving thirty tablets of perchloride of mercury 
in 30 gallons of water. 

Astringent baths. These are used in cases of irritable skin conditions. 
Examples arc alum — ^ pound to 30 gallons; boracic acid, sufficient to make 
a 2 \ per cent, solution, or alternatively 2 to 3 pounds of boracic acid may 
be added to 30 gallons of water; tannic acid is sometimes ordered, but the 
amount is always specially prescribed in each case. 

Acid and alkaline baths. Alkaline baths are frequently ordered in 
cases of chronic rheumatism, i pound of sodium bicarbonate being added to 
30 gallons of water. 

An acid bath is obtained by adding a gallon of vinegar to the water, or 5 
ounces of hydrochloric acid may be added, but this should be specially ordered. 

Stimulating baths are used to increase the circulation in the sub- 
cutaneous tissues and are believed to have a tonic effect on the general 
system. Examples of these are the ordinary cold bath, followed by a brisk 
rubbing; sea water bath, obtained by adding 7 pounds of sea salt to 30 
gallons of water; mustard bath, obtained by adding a pound of mustard 
to a bath of water, and it is advisible either to have the mustard in a 
muslin bag, or to mix it to a smooth paste before it is added to the water. 


AERATED AND FOAM BATFIS 

Eoam is made of tiny bubbles of air enclosed in a film of water, as when 
a ( hild blows bubbles with a clay pipe and soapy water. 

In the use of foam baths in medicine a foam-producing herb extract is 
employed. From i to 2 ounces is usually put into a small quantity of w^ater 
at the bottom of a bath, and an air-distributing apparatus is placed at the 
bottom of the bath, covered by the water. Gas, or air under pressure, is 
then passed in by means of this apparatus and escapes into the water 
which contains the foam-making extract, as fine bubbles of air, until the 
hath is half or threcquarters filled with foam. 

In the administration of an aerated bath foam is not used, but the 
hath is threcquarters filled with water, and air under pressure is then 
passed into the water by the apparatus mentioned above. Bubbles of air, 
y through the water to escape on the surface, cause movement by 
displacing the water through which they pass. This results in stimulation 
nr the circulation in the skin which causes the heart to beat faster at first, 
but after a few minutes acts as gently graduated exercise would do, and 
increases the tone of the cardiac muscle. This improves the force and 
volume of the pulse, and thus the circulation of the blood in all organs is 
unproved and the functions of the body are increased and metabolism is 



I I 8 GENERAL APPLICATIONS 

consequently carried on at a slightly higher rate, cellular activity is 
stimulated and a general feeling of wellbeing is brought about. 

A foam bath may be given for a vai iety of purposes. When it is used in 
order to increase the activity of the skin, as in chronic rheumatism and 
neuritis, the temperature of the water used to produce the foam is about 
115° F.; the bath is filled with foam and when the temperature of the 
small quantity of water at the bottom of the bath — ^some 3 or 4 inches — 
has cooled to 98®, the patient is allowed to get in. 

As he becomes used to the heat of the foam bath the temperature of the 
water at the bottom of the bath may be increased; and he sits in the bath 
for about half an hour perspiring freely. The sweat is constantly wiped 
from his face and brow by the nurse in attendance, who should watch 
his colour for any signs of distress and take his pulse at the temple, A foam 
bath is comfortable, since foam does not exert pressure as does water, 
and it may be prolonged without causing fatigue. 

In addition to the promotion of sweating the effect of this bath is to 
cause relaxation and dilatation of the superficial blood vessels, and the 
blood pressure is consequently lowered by it slightly. 

After a foam bath, the patient should be wrapped in warm blankets 
and allowed to lie still and rest for from an hour and a half to 2 hours; 
he may be given any warm drinks of his choice and will probably go on 
perspiring for some time. When the action of the skin becomes less and the 
patient has rested, he is sponged with warm water and allowed to have his 
own clothing on and, if he is in bed, his bed is made as usual. 

A foam bath may be produced by using compressed air. For this a 
special pump driven by electricity is required for delivery of air under 
pressure to the apparatus at the bottom of the bath; but in many instances 
either carbon dioxide or oxygen is employed. 

Carbon dioxide is found to be of special value in cases of hyperpiesis, as it 
stimulates the cutaneous circulation more than ordinary air and, with 
the relaxation of the vessels, blood pressure is lowered. As the work of the 
heart is rendered easier, the pulse will be found to improve and become 
softer and slower. The distress such patients suffer, from pulsation of the 
vessels in the neck, is also relieved; the relief of distressing symptoms, 
and the soothing effect of lying in a bath of foam is sedative and conducive 
to rest and sleep, provided the temperature of the bath is moderately low 
(see note on the use of oxygen, below). 

Oxygen may be employed as an alternative to carbon dioxide. If it is 
necessary to stimulate the metabolic activities of the body it is advisable 
to have the water in the bath at from 85° to 90 F.; but since oxygen, as a 
gas used in conjunction with foam, has been found to have a sedative 
effect, this effect will be enchanced if the water in the bath is cool, from 
65^ to 70®, A bath given at this temperature with the purpose of soothing 
and relieving insomnia due to mental symptoms of irritability, may be 
continued for between i and 2 hours. The patient does not feel cold, as 
foam prevents the escape of body heat — unless perspiration is induced, 
and this effect is not usually obtained in a foam bath at the temperature 
mentioned. 

Observations as described in the care of a patient having a vapour bath 
arc carried out. Drinks should be given throughout unless contra-ordered, 
and the treatment may be terminated in the same way. 



RADIANT HEAT BATHS 




RADIANT HEAT BATHS 

A form of heat sometimes employed as a general application is admin- 
istered by placing cradles fitted with electric light bulbs, arranged in rows 
on the apparatus, over the patient as he lies on the bed. The patient may 
be stripped and lying between blankets, the cradles being placed over 
him covered by blankets and quilt which should be tucked in at the 
bottom and sides of the bed, and carried closely up to the patient’s neck. 
A thermometer is hung at a convenient point on one of the cradles where 
it can be convenicndy inspected. Opinions differ as to whether the 
patient’s body should be exposed to the radiant heat or protected by a 
blanket or non-inflammable flannelette. 

The patient having been placed in position the current should be turned 
on and the rising temperature of the bed carefully watched. Radiant heat 
cannot be borne at greater temperature than 120"^ F. or a little over. The 
patient’s skin should be kept under constant observation, as if he per- 
spires it is possible that he will be badly burnt. During the administration 
of this form of treatment, the patient will probably feel uncomfortable, 
complaining that the heat in various isolated spots is almost impossible 
to bear. This is due to the fact that wherever moisture collects on the skin 
the heat rays seem to be absorbed, resulting in this uncomfortable degree 
of burning, which will not be relieved until the moisture has evaporated 
and the skin become quite dry again — and in the meantime, unless sweat 
is wiped off, the patient may be badly scalded. 

Similar observations to those described in the care which is maintained 
(luring the administration of a vapour bath should also be made. Radiant 
heat is not generally considered a good treatment for cases of nephritis, as 
the patient often becomes very hot and restless. It is probably most valuable 
as a local treatment for rheumatism and allied conditions where cellular 
activity and increased metabolism are desirable results; but as a form of 
heat applied solely for the induction of perspiration it is open to consider- 
able criticism. 


HOT BATHS AND HOT SPONGING 

A j)art from cleansing baths, hot baths and hot spongings maybe employed : 

{a) As a prophylactic to possible infection, and for the relief of shivering 
in persons who have been exposed to severe wetting and chilling, 

(b) As a prophylactic treatment at the outset of a severe cold in order to 
assist the skin to act, thus promoting diaphoresis and stimulating the sub- 
cutaneous circulation. 

(c) For the relief of fatigue following physical strain in conditions of 
exhaustion. 

{( 1 ) As an application of warmth in the treatment of shocJk and collapse, 
P u ticularly in aises where dehydration is a marked feature, as in infants 
suffering from diarrhoea and vomiting. 

{e) In spastic conditions, as when employed for the relief of muscular 
rigiclity in convulsions, and for the relief of restlessness in cases of chorea. 

The. articles required for bathing in a bath include under these 
special conditions a bath half full of water at a temperature of loo*^ F. The 
temperature will be raised gradually when the patient is in the bath to 
' or 1 10®. Bath blankets — one is used to cover the patient’s shoulders 



120 


GENERAL APPLICATIONS 


as he sits in the bath, and this blanket might be spread over the back part 
of the bath — a second blanket being used to cover the top of the bath so 
that the patient is sitting, with his shoulders protected and the bath 
covered, and his body, thus in contact with the steam rising from the water, 
is in no danger of becoming chilled. A cold compress might be needed for 
his head during the treatment, and he should be given hot drinks if 
possible. A chair with warm blankets or bathsheets should be placed in 
readiness beside the bath on which he can sit and be dabbed dry before 
he is carried back to bed. 

Throughout the treatment the nurse should stand by, taking the 
patient’s pulse at the temple, watching his colour^ the expression of his 
face for anxiety and distress, and the signs of perspiration which may be 
expected upon it. Any softne.ss, irregularity, compressibility of pulse, or 
general signs of distress would indicate the necessity for removing the 
patient from the bath at once and laying him flat between warm blankets 
until he had recovered. A stimulant might be required. 

The duration of the bath should be from lo to 15 minutes. At the end of 
this time the patient should be placed on the chair beside the bath, 
wrapped in warm bathsheets, gently dabbed dry and put back to bed to 
rest. His bed clothing should be warm woollen and he should have a 
blanket next to him as he will probably go on perspiring. The effect of the 
bath as regards the perspiration produced should be particularly noted. 
He should be given fluids throughout as these will make up for the amount 
of water lost by the skin, and prevent exhaustion or prostration. 


BATHS, SPONGES AND PACKS EMPLOYED IN THE 
REDUCTION OF TEMPERATURE 

General applications of cold are chiefly employed for the reduction of 
temperature. The water used is considerably below the temperature of 
the body. When immersion in a bath is employed, the water quickly 
absorbs heat and in this way the temperature of the body is fairly rapidly 
lowered; when packs and spongings are used, cooling is produced mainly 
by evaporation of the water applied to the surface of the body. Evapo- 
ration is more rapid and more effective when the surfaces which are being 
treated are being exposed to the air. When this method of sponging is 
adopted the treatment is described as ‘exposed sponging’. 

In some cases a liquid which evaporates more rapidly than water is 
employed — such as some form of alcohol, or a mixture of alcohol and water. 
The more rapid the evaporation produced, the more effective will the 
cooling process be. 

In addition to its effect in lowering the temperature of the body, the 
result of an application of cold improves the patient’s general condition. 
This is brought about owing to an increased circulation of blood in the 
subcutaneous tissue, which is one of the reactions expected to follow an 
application of cold, and partly also because of the reduction of toxaemia 
which results from stimulation of tissue activity and is followed by an 
increased elimination of the excretory waste products, particularly those 
from the skin and kidneys. 

The reduction of toxaemia, accompanied by relief of general discomfort, 
will in many cases render restless patients more comfortable and more 
peaceful, and so conduce to sleep. 



BATHS, SPONGES AND PACKS EMPLOYED 12 I 

At the commencement of a general application of cold, particularly when 
Brandt’s bath is used or a very cold pack given, the patient may shiver 
violently, but this should not continue. In the first place it is due to con- 
traction of the involuntary muscles in the skin in an endeavour to produce 
heat, and this is accompanied by contraction of the involuntary muscles 
in the blood vessels of the skin which should soon be followed by an im- 
provement in the circulation generally, when the shivering will cease. 
Prolonged shivering would be an indication that the treatment should 
cease and would suggest that the patient’s general condition is too low 
to respond to the treatment by the expected reaction. Nurses will rarely, 
if ever, meet with this emergency, as the physician will have considered 
the patient’s condition before a general application of cold is ordered. 

As the result of improvement of the circulation the action of the heart 
is improved, and this is manifested by a fuller and stronger pulse; but when 
a fairly drastic application of cold is made the pulse may become weak 
and rapid and barely perceptible at the outset, and if such untoward 
symptoms are very marked a dose of brandy is often given, to facilitate 
promptness of reaction, and a few minutes later the expected improvement 
will be noticed. It is for this reason that a dose of brandy is always pre- 
pared and almost invariably given when Brandt’s bath is administered. 

The methods by which applications of cold are generally made include 
tepid and cold sponging, cold packs, Brandt’s bath, ice cradling and, 
much more rarely, affusion. 


SPONGING 

Either tepid water {tepid sponging) between 75° and 80*^ F., or cold water 
[cold sponging) below 70^ F., may be used for the reduction of temperature, 
and this form of treatment is frequently employed when it reaches 103° 
or over. In some cases of delayed toxaemia, sponging is employed when- 
ever the temperature reaches 102^ F. 

T'he articles required (see fig. 44, p. 162) are, tepid or cold water ^ 
and either a jug of cooler water or some pieces of ice, in order to keep the 
te mperature of the water even, as the heat of the patient’s body is trans- 
Icrred to it by the sponges used. A lotion thermometer should be kept in the 
\\ ater so that any rise of temperature can be observed. It is usual to begin 
the sponging with water at the maximum degree of temperature 
mentioned, namely 80° F., gradually cooling it to 75"’. 

Several sponges will be required; some sisters use four, others use six or 
f ight. Two sponges should be used alternately, for the actual sponging 
treatment, and the spare sponges may be placed in contact with difl'erent 
parts of the skin of the patient’s body, such as the nape of his neck, the 
axillae and groins. He may be given a sponge to hold in his hands, the 
^>t>jert of these extra sponges being to cool parts of the body where heat 
proves very uncomfortable, and in parts where the skin is thin, and a 
hlxTal blood supply present — as in the axillae and groins — where rapid 
Pooling may take place, 

\face towel is supplied for drying the face — the only part of the patient’s 
hotly which is dried. The water is allowed to evaporate from the remainder 
skin, as it is by tliis evaporation that cooling takes place. 

A tray should be ready prepared for the ordinary routine treatment of 
the hack, and this will be performed at the termination of the sponging. 



122 


GENERAL APPLICATIONS 


Two thin bath blankets or bathshects arc placed — one beneath and one 
above the patient — unless a sheet — ^which is cooler — is preferred for 
covering him. Some sisters put a mackintosh beneath the under blanket, 
but this should not be necessary if the sponging is carefully performed 
and the water not allowed to run on to the b^. 

A pail should be ready at the bedside, in case it becomes necessary to 
change the water, as might happen when tepid sponging is being carried 
out, because the heat of the water rises rapidly, and the addition of cold 
water to the basin may not be sufficient to keep the temperature of the 
water even. It is a good plan to have two basins at the bedside, one of very 
cold water in which to wring the sponges out after taking them off the hot 
body, before transfening them to the second basin which contains the 
tepid water that is being used for sponging. 

Method. The patient having been prepared ready stripped beneath a 
sheet or blanket as described, his face is sponged and dried. This makes 
him feel more comfortable, and if extra sponges are used these arc then 
placed against the parts of the body chosen. The nurse now proceeds to 
work with two sponges alternately — first the upper extremity is sponged, 
working on the arm on the opposite side of the bed to that on which the 
nurse is standing. She grasps the hand of the arm undergoing treatment 
and, holding the sponge as full of water as possible, passes it slowly over the 
skin from the top of the shoulder to the fingertips, taking care to see that 
small beads of water are left on the skin. The hand with which the nurse 
holds the sponge must be relaxed, otherwise she will squeeze water out of 
it, and little rivulets will run on to the bed. 

Having made the first stroke she places the used sponge in the cold water 
to cool it and proceeds with the next stroke; eight or ten strokes should 
conclude the treatment of an upper limb, and this should occupy from two 
to three minutes. The limb is then placed by the side of the patient's 
body either beneath the covering sheet or allowed to lie above it. The 
other arm is then sponged in the same w^ay. It gives the patient pleasure 
if he is allowed to dabble his hand in the bowl of water at the conclusion 
of the treatment of each arm, and the basin may be held over the bed for 
this purpose or allowed to rest on the bed, and whilst the hand is in the water 
the nurse swills the tepid water up over the forearms as far as she can. 

The stationary sponges are changed from time to time as considered 
convenient, but they should, if possible, be changed from at least four to 
six times during the treatment. 

The front of the body is next treated, and the strokes of the cool wet 
sponge over the front of the chest should be made in circles, not just back- 
wards and forwards, as vertical strokes with a cold wet sponge might 
cause the patient to flinch or gasp. At the sides of the body, the strokes 
may be vertical, but the subcutaneous tissue is thick in this area and the 
sponging hereabouts should occupy from three to four minutes. 

The lower extremities come next, one limb being sponged at a time. 
It may be flexed at the hip and knee, with the foot placed flat on the bed, 
but it must be supported by the nurse; or the limb may be sponged lying 
flat on the bed and lifted whilst the under part is treated. The treatment 
of the lower limbs should occupy from eight to ten minutes, and roughly 
from twelve to fourteen strokes of the sponge from top to bottom will be 
sufficient. If it can be managed, a basin should be placed on the bed and 



SPONOINO 


123 

each foot in turn held in the basin, the nurse swilling the water up over the 
lower leg as she did in the case of the forearm. After removing the foot 
from the water and placing the bowl on the locker, she should separate 
the toes and remove any excess water from the hollows between them. 

Special attention should be paid to the groin, the inner aspect of the 
thigh and the popliteal space. The skin is comparatively thin in these areas, 
and hot spots are very frequent here, and treatment of these materially 
assists in cooling the body by a reflex effect. 

Finally the patient is turned, if permissible, and his back is sponged. 
The tissues of the back are very thick. Long sweeping strokes should be 
made with the wet sponges, and special attention paid to the thick muscles 
on either side of the spine. At least five minutes should be taken in sponging 
a back — and more, if as so often happens the patient finds it very comfort- 
ing and soothing. In order to save turning the patient again, the toilet of 
the lower part of the back is carried out for the prevention of pressure 
sores. The bath blanket or sheet beneath the patient is taken out, the 
patient’s personal clothing put on, and the bed made up as usual. 

Throughout the treatment, whenever possible a cold compress should 
be kept on the patient’s forehead, and changed as often as necessary in 
order to keep it cool. He may also have a hot water bottle at his feet, 
although this is not invariably used. 

Recording the temperature. The temperature is taken ten minutes 
after the sponging and the result charted — a fall of between two and three 
degrees being considered satisfactory. The temperature obtained by 

A.M. RM. AM PM. A.M. P.M. 



Fio. 13. 

^ cpid sponging for reduction, of tcmp>craturc in high fever. Note that the effect of spong- 
is maintained for 24 liours, when tlic temperature is’ very high again. At this point 
sponging would, very likely, be repeated. 


GENERAL APPLICATIONS 


124 

Sponging a patient or reducing fever by any similar method is charted as 
described on the accompanying illustration (fig. 13). 

Observation of patient’s condition. The general condition of the 
patient should be very carefully watched for any signs (already indicated 
on p. 120) which would suggest that the reaction expected would be 
retarded or absent. Untoward signs include weakness and irregularity 
of the pulse; pallor or cyanosis; anxiety of facial expression, the appearance 
of perspiration on the face; complaints of palpitation and sighing or ir- 
regularity of respiration. Such signs are comparatively rare, and they arc 
more likely to be caused by injudicious movement and undue exposure of 
the patient during this treatment than by the cold applications themselves. 
Should they occur, however, treatment might be suspended for a time 
and the patient given a warm drink; a stimulant may be necessary in 
some cases, and he should be covered up and kept warm for a few minutes 
before the treatment can safely be continued. 

Exposed sponging. This more drastic form of treatment is carried out 
in exactly the same way as described above, but the patient, instead of 
being covered by a sheet, lies naked and exposed on the surface of his 
bed, wearing only a loincloth or a towel to cover his loins. The exposure 
of the surface of the body to the air causes rapid evaporation and cooling, 
and the treatment must be quickly performed if chilling is to be avoided. 


COLD PACKING 

Either cold or iced water may be employed in the application of a cold 
wet pack. 

The articles required are — three drawsheets, ready in a pail or bath 
of water by the bedside; a long bed mackintosh, and a bath blanket or 
bathsheet is placed beneath the patient, a second bath blanket or sheet 
being needed to cover him. A cold compress or an icebag is applied to 
his head. A stimulant should be at hand in case of necessity and a choice 
of drinks — hot, warm or cool (see fig. 45, p. 163). 

Method. The patient is stripped and lies between the bath blankets on 
his bed. The pail or bath containing the sheets to be employed for the 
pack are brought to the bedside. One sheet is wrung out and rolled 
beneath the patient’s body, and this may be of either single or double 
thickness. A second sheet is wrung out and placed over the front of the 
patient’s body beneath the covering bathsheet, which is then removed. The 
cold wet sheet is packed closely round the patient’s neck (in the accompany- 
ing illustration the wet sheet is shown folded back), and a fold of it lies in 
contact with the sides of his body so that his arm is not touching his hot 
body but is separated from it by layers of wet sheeting. The sheet is carried 
over his arms as they lie beside his body and tucked round them. The 
upper wet sheet is tucked in around his legs so that, as far as possible, 
wet sheet is in contact with all parts of the surface of the body, and a cold 
compress is applied to his head. 

The nurse stands by the bedside, making observation of the patient’s 
condition as described for sponging. She notes that steam rises from the 



COLD PACKING I 25 

wet sheet as evaporation of the moisture in contact with the patient’s hot 
body takes place. When the sheet becomes warm she wrings out the second 
sheet, and changes it with the one on top of the patient, placing the warm 
sheet in a pail of iced water to cool it. 

The sheet which lies over the patient is changed in this way about 
every three minutes, and as the duration of the treatment is from fifteen 
to twenty minutes it can be changed five or six times. It is not usual to 
change the wet sheet on which the patient lies more than once or twice 
during the treatment, and even this depends very much on the advisability 
of moving him at all. In some instances, where movement would be 
dangerous, a wet sheet is not put under the patient at all, but the upper 
sheet is tucked in as far as possible over the sides of the body and com- 
pletely round the limbs so that they are enveloped by it. The patient 
should be given drinks at fairly frequent intervals during the treatment. 

At the end of the treatment the wet pack and bath blankets and 
mackintosh are removed, the toilet of the patient’s back is performed, 
his personal clothing is put on, and his bed made up as before; and then 
after ten minutes, as in the case of sponging, his temperature is taken and 
charted. The temperature recorded at this time indicates the effect of 
the treatment, and it will probably be found to have reduced the degree 
of pyrexia by some 2*^ or 2 

BRANDT'S BATH 

Brandt’s bath is the most drastic form of cold application that is ever 
practised in this country, and it is both cumbersome in use and severe in 
its effects. It requires very careful nursing observation, and for these and 
many other reasons it has fallen into comparative disuse. If, however, ideal 
conditions can be secured for carrying out this treatment, it is the form 
best suited for the reduction of temperature in cases in which grave 
toxaemia is present, and only those who have used it and have seen its 
effects can possibly appreciate its value. 

Method. A bath is wheeled to the bedside and the patient, who is 
already undressed, is placed on a specially devised stretcher furnished 
with air ring cushions for the support of head, shoulders and buttocks, 
and is gently lowered into the water which, in many instances for a first 
ticatment, is prepared at from 85^ to 90'’ F. The patient is immersed, 
(‘xcept for head and shoulders, and two nurses, one on each side of the 
bath, swill water from sponges over the patient’s chest and shoulders. They 
watch his colour and note his pulse, and give him drinks and stimulants as 
necessary. It is quite usual for the patient’s pulse to become very weak, and 
sometimes to disappear altogether on immersion, while his face will be- 
come pale and grey. At this stage he is given a stimulant, and in a few 
moments his colour will be seen to improve, while his pulse at the same 
time increases in volume and strength. 

The duration of the bath may be three minutes, or from five to ten minutes, 
1 'or a first treatment the temperature of the bath is not usually lower than 
^5'^, but for subsequent treatments, and even in the first instance if the 
patient can stand it, the temperature of the bath may be lowered lo' or 
-io'’ by gently pouring in iced water at the comers and stirring it up to 



126 GENERAL APPLICATIONS 

reach the surface of the body whilst the patient is undergoing treatment. 
In this way the temperature of the water may be lowered to 65® F. 

At the termination of the treatment the patient is lifted out on to a 
bed on which a mackintosh has been placed. The stretcher on which he 
lies is removed, and at the same time a bath blanket is rolled beneath 
him. He is then covered by a light blanket or bathsheet and allowed to 
remain undisturbed for half an hour. At the end of this time his tempera- 
ture is taken in order to record the effect of the bath, his clothes are put on 
and his bed made up as usual. 

ICE CRADLING 

Ice cradling is a form of cold application which is gentle compared 
with those already described and, although it may be used for the reduc- 
tion of fever, it is probably more generally used to cause a gradual re^duc- 
tion of the temperature of a patient’s bed during very hot weather, or in 
very hot climates. 

The articles required (sec fig. 46, p. 165) include an ice cradle^ pos- 
sibly of the pattern in which a dozen or two of specially devised ice pails 
are suspended from cradles placed over the patient’s body — in which 
case the contents of the pails will require changing as the ice melts; 
or it may be that special trays are suspended from the cradles, fitted with 
a device for draining the water from the ice as it melts, and in this case 
it will only be necessary to renew the freezing mixture from time to time. 

A bath thermometer is suspended from one of the cradles, and a clinical 
thermometer will be required for recording the patient’s temperature, 
which is taken from time to time. 

A small blanket should be provided for covering the patient’s feet, and 
he may be given a hot water botde, as his feet should not be allowed to 
get cold, since this would not only cause him discomfort but might also 
result in lowering his vitality. 

Method of application. The patient lies undressed on his bed beneath 
a covering sheet. The cradles are placed over him and the receptacles con- 
taining ice arc filled with a freezing mixture of ice and salt. They may be 
covered by flannel bags, particularly when the pails arc used. The ther- 
mometer is suspended from about the middle of one of the cradles, but 
should not be too near the receptacles containing ice. 

A sheet is placed over the cradle, and the sheet next to the patient is 
removed. It wll be remembered that his feet arc covered by a small blan- 
ket and that he has a hot water bottle near them. The sheet covering the 
cradles should be looped up at each side so as to allow air to pass freely 
over the patient’s body, since cooling takes place by this continuous move- 
ment and thus assists in the evaporation of moisture from the patient’s 
skin. (In the illustration, fig. 43, p. 165, the sheet is shown folded back so 
that the position of the cradle and ice pails can be seen.) The cold com- 
press applied to his head should be renewed from time to time. 

The Nation of this treatmmt may be three hours, or more; and it may be 
fairly continuous in hot weather. The patient’s temperature should be 
taken evory hour or every two hours to ensure that the treatment is not 
proving too severe. 



AFFUSION 


127 


AFFUSION 

Affusion is a method of reducing temperature by pouring cool or cold 
water over the body of a patient who lies on a mackintosh and sheet, the 
mackintosh being so arranged that water can be directed from it into a 
pail or pails at the bedside. The patient may wear a cotton garment, or 
he may be-stripped and covered only by a single layer of cotton sheet. By 
means of small watering cans water is sprinkled over his body and allowed 
to run into the pails at the bedside. The height from which the water is 
poured increases or decreases the tonic effect of this treatment and of the 
consequent reaction. 



Chapter 9 

The use of Enemata and Suppositories 

The administration of an enema — The use of a flatus tube — Varieties of enemata — 
Giving enemata to babies and infants — Suppositories 

/mn enema is an injection into the lower bowel. The word is usually 
employed when the injection is given with the object of washing 
JL JL out and evacuating the contents of the bowel. In a few instances 
it is given for purposes of treatment of the bowel, or the introduction of 
fluid and drugs which are meant to be retained and absorbed. These 
include astiingent, sedative, stimulating and anaesthetic substances. 

An enema which is to be returned may be given by means of a rubber catheter 
and tubing and funnel, or by an irrigation can (see fig. 47, p. 166), or by 
Higginson’s syringe to which a short rubber tube is attached as the use 
of an unguarded bone nozzle is inadvisable, because the mucous lining of 
the rectum can be so easily injured or even perforated by it. 

Requisites. The apparatus shown in fig. 47, consists of an irrigation can, 
tubing and rectal catheters, short flatus tul:)e, soap solution, swabs, lubri- 
cant and a thermometer. A mackintosh and drawsheet to protect the bed 
may, but should not usually, be necessary. 

The solution to be injected should be prepared in the reservoir at the 
desired temperature. It is sufficient to say that unless otherwise ordered 
the fluid should not be hotter than 90'' to 100'' F. 

Preparation of patient. If the patient is in a fit condition the prof)Osed 
treatment and the result expected should be explained to him; for example, 
if a cleansing enema is to be given, he should be told that this enema will 
be injected very slowly and carefully and that he will retain it for probably 
a quarter of an hour, when it will be returned with an evacuation of the 
bowel. Tell him also that the necessary bedpan will be at hand should he 
desire to use it earlier, but that the best results will be obtained by his 
co-operation, in retaining the enema for a short time. 

The bed should be screened and the articles placed ready on the right- 
hand side. The bedclothes are then turned down to the foot of the bed 
leaving the patient covered with a blanket. If it is possible to move him it 
is best to give the enema with the patient in the left lateral position; he 
is brought to the right side of the bed, his personal clothing moved out 
of the way, his knees drawn up and the uppermost leg is flexed across the 
other, resting on the bed in front of it, in order to steady his position. The 
pillows should be comfortably arranged. It is important to ensure that 
the patient is quite comfortable, and then he will be relaxed during the 
performance of the treatment. 

The rectal catheter is lubricated and passed four or five inches into the 
rectum. A pint or pint and a half of fluid is ordinarily used for a cleansing 
enema; it should be slowly administered, taking about 5-7 minutes. If the 
patient complains of any discomfort the nurse should stop the treatment 
for a few moments, encourage him by telling him that all is going well, see 
that he is breathing evenly, getting him to breathe through his mouth if 

128 



USE OF ENEMATA AND SUPPOSITORIES I 29 

necessary in order that his muscles, particularly those of the abdomen, 
should be fully relaxed. 

When all the fluid has been injected the nurse watches the patient care- 
fully and, when a suitable moment comes and he appears relaxed and 
coinfortable, gently withdraws the rectal catheter. If she notes that this 
seems to act as a slight source of irritation, which might stimulate peristalsis, 
she might separate the catheter from the apparatus and secure the end of 
it with a rubber tubing clip or spigot instead of withdrawing it. 

She covers the patient with all his bedclothes but does not necessarily 
alter his position; it is better if he can continue to lie quite still for a short 
time, but she should stay near him, and if he expresses a desire to return 
the injection she should attempt to avoid this happening by explaining 
the necessity of retaining it. A folded towel pressed against the anus or 
holding the buttocks pressed together in order to restrain that bearing 
down feeling which makes the patient think that the return of the injection 
is imminent may help. 

Observation. The contents of the bedpan should be inspected and report 
on the character of the result of the enema made, as to whether it is 
merely coloured fluid, contains only particles of faeces or is a good action. 
The character of the stool should be stated, and whether it is constipated 
or not; the presence of any abnormal constituents or abnormalities of 
shape, colour, &c., and the passage of flatus should be noted. 

When an enema is given to relieve retention of urine it is important to 
discover whether urine is passed and for this purpose the returned enema 
must be measured and compared with the quantity given, unless evidence 
from some other source is obtainable. 

When an enema is given in order to be retained similar preparation is made, 
but the injection should be administered very slowly and always be pre- 
ceded by passing a flatus tube. For example, if from 4 to 6 ounces of starch 
is given in order to allay bowel irritation, about 10-15 minutes would be 
occupied in administering it. When saline is administered, 8-10 ounces 
may be given in 20 minutes, see fig. 50, p. 167 (unless the drip method 
is utilized when a special apparatus is employed). The rate of flow then 
varies from 40 to 60 drops per minute. 

The enema should be given with the patient in a position in which he 
can remain, so that he need not be disturbed for some time after the 
injection, and he should not be subject to any irritation or anxiety about 
the matter. 

To pass a flatus tube the anal region should be swabbed clean, the tube 
lubricated and passed into the rectum, sufficiently far to tap the flatus 
beyond the internal sphincter. The distal end of this tube is attached by 
means of a glass connexion (see fig. 49, p. 167), to a piece of rubber tubing 
with a sinker or funnel attached to its free end. This enables the end of the 
tubing to be retained in a bowl of water or lotion, and by this means the 
flatus from the bowel can be made to bubble through the fluid and 
the amount of flatus expelled can be roughly estimated. 

Varieties of enemata. These arc divided up into groups, named 
according to the result to be obtained or the substance which is to be used. 

An evacuant enema is given for the purpose of emptying the lower 
bowel. Plain warm water is the simplest form, and this is sometimes 
described as a simple enema — enema simplex — though this term is also 



1 30 USE OF ENEMATA AND SUPPOSITORIES 

generally used to describe a soap and water enema, more correctly desig- 
nated — enema saponis. 

Soap and water enema. A good common yellow soap, a quarter of an ounce 
to a pint of water may be used. The soap should be finely shredded before 
mixing. Soap jelly made by dissolving soap in water in such proportion 
as to form a jelly. To prepare an enema one ounce of this jelly is added 
to a pint of water. 

In hospital practice a prescription containing pure soap may be avail- 
able or some pure soap jelly. 

From I to 2 pints is usually ordered — the soap must be thoroughly 
dissolved and mixed with the water and, if ordinary soap is used, the 
mixture should be strained through a fine sieve or gauze to remove any 
particles. The injection should be given warm, at about the temperature 
of 80° to 90° F., and not above 100°, and all soap bubbles should be 
removed from the top of the fluid as these hold air. 

In some hospitak it is the routine practice to add half to one ounce of 
olive oil to a simple enema in order to make it less irritating and more lub- 
ricating. 

Olive-oil enema. From 6 to 20 ounces of warmed olive oil constitutes 
an olive-oil enema, although many authorities advocate the mixing of 
from 4 to 8 ounces of olive oil with equal quantities of warm water or soap 
and water; the nurse should therefore inquire as to the practice of the 
hospital, or the wishes of the physician before she gives this enema. In 
some cases a soap-and-water enema will be ordered to follow an olive-oil 
enema an hour or so later. 

An olive-oil enema is given with a large catheter, or a rectal tube and 
glass funnel, and the apparatus should be prepared in hot water to keep 
the rubber as pliable as possible and so facilitate the passage of the warmed 
oil. The apparatus should be immersed in soap and water after use in 
order to cleanse it of oil. 

Olive-oil-and-glycerine enema. Equal parts of olive oil and glycerine may 
be administered in the same way as the enema described above. 

Glycerine enema. A small quantity of glycerine — ^from 2 to 8 drachms — is 
injected into the lower bowel in order to extract water from the walk of 
the rectum and so facilitate the breaking up amd passage of hard, impacted 
faeces which may be lying there. A special vulcanite glycerine syringe is 
often provided for thk purpose, but its use is to be deplored as the hard 
nozzle may injure the rectum. It is better to use a short rectal tube and 
glass syringe for this injection (see fig. 51, p. 168). 

A mixture of glycerine and warm water is frequently used to obtain 
evacuation of the bowel when a slightly lubricant clfect is desired. Two to 
four ounces of glycerine with equal quantities of water is the usual pro- 
portion given, and it is given by means of a catheter and funnel. 

Purgative enema. Although a cleansing enema produces an evacua- 
tion of the bowel it is not definitely purgative. A purgative enema contains 
some purgative substance. 

Castor-oil enema. Two to four ounces of castor oil is mixed with double 
this quantity of olive oil and given by means of a large rubber catheter, 
tubing and funnel. 

Ox-bile enema. Two to foiur drachms of ox bile is mixed with 4-8 ounces 
of sterch mucilage or warm water. 



USE OF ENEMATA AND SUPPOSITORIES I3I 

Magnesium^-sulphate enema. One to two ounces of magnesium sulphate is 
mixed with 4-8 ounces of starch mucilage or warm water. 

Aloes, 20-30 grains may be given slowly in mucilage or warm water. 

It will be noticed that only small quantities are injected in these in- 
stances. The object is that the enema shall be retained for an hour, 2 hours 
or more, and so effect a better action. Should a purgative enema not be 
returned witiiin four hours, it may be followed by a small soap-and-water 
injection. A magnesium-sulphate enema is also employed as a special 
treatment for the relief of oedema in cardiac and renal cases by assisting 
in the elimination of water. 

Carminative enema. A carminative enema assists in the expulsion of 
flatus. 

Turpentine, One ounce of turpentine is usually mixed with two ounces 
of olive oil, unless a special prescription is ordered. The mixture is shaken 
up in order to emulsify it and then added to a pint of soap-and-water 
enema solution. An alternative mixture is i ounce of turpentine added to 
4 ounces of olive oil or to 4 ounces of starch mucilage. 

Asafoetida, Thirty grains of asafoetida are administered in a small quan- 
tity — about 4-6 ounces — of starch mucilage. 

Alum, Two ounces of powdered alum are dissolved in from i to 2 pints 
of tepid water. 

Molasses, Tliree ounces of molasses well mixed with 3 ounces of warm 
milk may be given. Black treacle may alternatively be employed. Some 
phyTsicians order the treacle to be given in 15 ounces of warm water or 
mucilage, instead of in milk. 

Anthelmintic enema. I'his enema is used in the treatment of thread- 
worms which migrate to the lower part of the bowel. 

Infusion of quassia. 

Cold salt and water, A hypertonic solution is made by adding two drachms 
of salt to a pint of water. 

Astringent substances decrease the secretion of mucus by causing 
constriction of the blood vessels in the bowel wall. An astringent enema 
is ordered in the treatment of dysentery characterised by diarrhoea; the 
stools containing blood and mucus. The substances employed are specially 
ordered in each case, and include — nitrate of silver solutioHy 0.2 per cent., and 
tannic acid, 2 per cent. 

Sedative enema. A sedative substance added to an enema diminishes 
the number of stools, and is therefore used in the treatment of some forms 
of diarrhoea, particularly in typhoid fever. 

Starch and opium is the commonest sedative mixture administered by the 
rectum, from 20 to 60 minims of tincture of opium is mixed in a small 
quantity — usually 2-4 ounces — of starch mucilage; the mixture is given 
cool and injected very slowly. 

Starch mucilage^ barley mucilage^ gum tragacanth, or any other mucilaginous 
substance may be administered to allay irritation and diminish the fre- 
quency o( stools. A smadi quantity (not more than 5 ounces) is given, the 
object being to form a coating on the inner surface of the mucous mcm- 
l)ranc. This tends to relieve tenesmus. 

Starch mudlagc is made by mixing 2 drachms of powdered starch to a 
smooth paste with a little cold water, and then pouring boiling water up 



132 USE OF ENEMATA AND SUPPOSITORIES 

to a pint on to it as in making starch for laundry purposes. The prepara- 
tion should be sufficiently tacky to coat a spoon lightly. 

Stimulating enema. A stimulating enema is given to allay shock as in 
the treatment of dehydration following loss of b^y fluid or collapse. It 
also increases body heat and for this reason is administered in the state 
of coma and collapse which follows opium poisoning. 

Normal saliney which is practically a teaspoonful or a drachm of salt to 
a pint of water, can be obtained in almost any circumstances and is the 
fluid ordinarily used. In hospital it is usual to have special tablets con- 
taining 40 or 80 grains, and either one 80 giain tablet or two 40 grains 
are used to the pint. Some authorities advocate that saline should be given 
at a slightly higher temperature than the average enema, but generally 
speaking it is better for all rectal injections to be not hotter than loo"^ F. 
A saline may be ordered as one single treatment such as is given when a 
patient is brought back from the operating theatre and it is desired to 
increase his body heat at once. Or salines may be administered at regular 
intervals, over a period of time, to patients who are in a state of collapse, 
or to those who are dehydrated by the continual loss of body fluid, as in 
cases of profuse bleeding, or vomiting, and also to those who for some 
reason are unable to receive an adequate amount of fluid by the usual 
means. The apparatus shown in fig. 47, p. 166, may be Employed or a tube 
and funnel may be used as in fig. 50, p. 167. A flatus tube should first 
be passed. 

Continuous administration of rectal saline is often better treatment 
than the giving of small quantities at intervak — for the description of 
methods see pp. 196-7. 

Coffee. Five ounces of strong black coffee to which a pinch of salt has 
been added is sometimes administered as a stimulant in the treatment of 
the coma and collapse following opium poisoning. 

Nutrient enema. At the present time pre-digested foods are not given 
by rectum but the capacity for absorption of fluid by the bowel is made use 
of in many instances. For purposes of feeding, a solution of glucose is used; 
in order to allay thirst, plain water may be administered; and, in order 
to prevent or combat any possible acidosis following an operation, water 
containing a teaspoonful of sodium bicarbonate to the pint may be given. 
The value of normal saline has already been mentioned. 

Medicinal enema. Medicines may be given per rectum under certain 
conditions, particularly in the case of unconscious patients, in disorders 
of the stomach and when vomiting is persistent. 

When this method of drug administration is used it is customary for 
the physician to order double the dose that would ordinarily be given by 
mouth. The drugs most commonly given per rectum are potassium bro- 
mide and chloral in cases of epilepsy. 

Anaesthetic enema. Rectal administration of certain drugs is some- 
times employed for the purpose of induction of general anaesthesia. 

Avertin is employed in a 2^ per cent, solution as a basal narcotic to pro- 
duce anaesthesia. The amount of avertin used is i to 2 grains per pound 
of body weight, and the dose is carefully worked out for each patient. 
The average total quantity administered varies from 4 to 8 oimces as 
required. 



USE OF ENEMATA AND SUPPOSITORIES 1 33 

In preparation, the patient is given an aperient or an enema the previous 
evening, and in some cases a sedative such as sulphonal is given overnight. 
A light breakfast may be taken on the morning of the operation. Before 
avertin is administered the patient is prepared for the operating theatre. 
In some cases an injection of morphia and atropine is given, in all cases 
the patient is permitted to pass urine, any special clothing employed for 
theatre use is put on, and dentures arc removed. Everything should be done 
as quietly as possible, all fussiness or anything that will irritate the patient 
being avoided, particularly if the case happens to be one of thyrotoxicosis. 
He may then cither be put on the trolley on which he is to be conveyed 
to the theatre, or the canvas of the stretcher on which he is to be lifted 
may be placed under him as he lies on his bed, the latter method being 
preferable as it ensures that the patient will lie comfortably in his bed 
during induction. The injection is made by means of a catheter, tubing 
and funnel — there is no necessity to move the patient into the left lateral 
position as the injection can be given while he lies on his back. A flatus 
tube is passed, the injection is slowly made, the nurse watches the patient 
carefully and as soon as he falls asleep or becomes unconscious she ceases 
the administration even though the full amount ordered may not have 
been given. The injection is made as slowly as it can conveniently be given; 
some authorities prefer that only half the amount ordered should be ad- 
ministered at first, and then a short pause made — and the administration is 
continued until the patient becomes unconscious. 

Ether, Ether may occasionally be given by rectum in order to produce 
general anaesthesia, but as colitis may result it is now rarely employed. 
The mode of administration is as follows — The lower bowel is washed out, 
usually the evening before; a hypodermic injection of morphia and atro- 
pine is administered half an hour before the rectal injection of ether is to 
be made, and the patient is prepared for a general anaesthetic as described 
in the case of avertin. A 5 per cent, solution of ether and oil, well shaken 
up, in order to ensure emulsification, is slowly passed into the rectum by 
means of a catheter and funnel. The amount of ether to be given is always 
specially ordered. 

The nurse watches the patient carefully throughout the administration. 
His legs will first become numb, then his arms, and finally he v/ill become 
unconscious. 

In order to prevent colitis, immediately the operation is over, colonic 
lavage is administered until all odour of ether h2is disappeared. 

Giving enemata to babies and infants. Although the term enema 
is used, when this treatment is given to a tiny baby, the rectum is merely 
irrigated with from 2 to 4 ounces of plain water or weak boracic lotion, at 
a temperature not exceeding So'’ F. As a rule the infant is placed on the 
nurse's lap, her knees arc protected by a mackintosh, the infant’s buttocks 
are slightly raised on a folded tow^el as he lies on his back, the fluid is 
allowed to run in very gently, and is then siphoned back into a receptacle 
placed on the floor or on a stool in front of the nui'se. 

With children over two years of age a small quantity — from 4 to 6 
ounces — of water, containing very little soap, making a weak solution, 
may be administered gently with a catheter and funnel. The child should 
be placed upon a chamber to evacuate his bowel. 

The nurse may attempt to frustrate any urgent desire the child may have 



134 USE OF ENEMATA AND SUPPOSITORIES 

to return the fluid immediately, by pressing his buttocks together foi a few 
minutes. If there is any tendency to prolapse of the rectum the child 
should not be placed on a chamber but should be allowed to return the 
enema while lying on his side on the bed, the nurse catching fluid and 
faeces into a receiver as they are ejected. 

Enema rash. In some — comparatively rare — instances a rectal injec- 
tion, particularly one of soap and water, is followed by an enema rash. 
This is very similar to a serum rash and usually combines the characters 
of an erythematous, urticarial, and papular rash. 

SUPPOSITORIES 

Suppositories are usually cone-shaped, solidified preparations contain- 
ing lubricants or drugs. A glycerine suppository is made of glycerine, solidified 
with gelatine. It is used when it is desirable to empty the rectum of faecal 
contents which for some reason may have become arrested there. 

A glycerine suppository may be dipped in warm water, which renders 
it lubricated; other types of suppository need vaseline. With the patient 
in the left lateral position, as for giving an enema, the suppository should 
be passed beyond the anal canal into the rectum by means of a gloved 
finger. When a suppository is given to children it is necessary to hold the 
buttocks pressed together for a few moments, otherwise it will immediately 
be ejected. Great care must be taken to insert tiie suppository slowly and 
carefully in order to prevent injury to the mucous membrane of the 
bowel. 

Suppositories containing belladonna, and moiphia or opium, are made 
up with a base of oil of theobroraa, except in hot countries, where this 
would melt, when purified beeswax is used instead. When the suppository 
contains any substance which is to be retained, its administration 
should be preceded by the passage of a flatus tube (see fig. 52, p. 168) in 
order to leave the rectum quite free of air; or by the administration of an 
enema if the rectum is loaded with faeces. 

After the insertion of a suppository which contains a sedative it is important to 
place the patient in a jx)sition in which he will be quite comfortable and 
able to rest. 



Chapter lo 

Irrigation, Lavage, Douching and 
Catheterization 

Gastric lavage — High colonic irrigation — Catheterization and bladder irrigation and 

drainage — Vaginal douching 

GASTRIC LAVAGE 

T he washing out of the stomach is performed for the removal of 
poison which has been swallowed, and in some cases in order to 
cleanse the stomach before an operation is performed upon it, as 
for example when a patient with an acute abdominal condition is vomiting 
large quantities of fluid. Gastric lavage is also sometimes employed in the 
treatment of post-operative vomiting when this symptom is troublesome 
and persistent. 

The apparatus required includes (sec fig. 53, p. 169) iX Jaques's rubber 
stomach tube with Vi funnel attached. 

A mouth gag and tongue forceps ^ a lubricant for the tube, plenty of lotion and 
a lotion thermometer, a mackintosh and towel may be needed to protect 
the bed, a pail for the returned fluid and either articles for cleansing the 
patient’s mouth after the treatment, or a mouth-wash, if he is in a con- 
dition to use one, should also be provided. 

Method. There are instances in which a stomach is cleansed by passing 
a Ryle’s tube (as described in the administration of a test meal on p, 215). 
This method is undertaken when a surgeon wishes the resting juice with- 
drawn and the stomach cleansed by pitssing in a small quantity of fluid 
by means of a large syringe and withdrawing or aspirating this fluid back 
by the same means. 

But for gastric lavage employed for washing poison out of the stomach 
large quantities of fluid should be used, as described by H. K. Marriott 
in ‘The Treatment of Acute Poisoning’ and employed by him at the Mid- 
dlesex Hospital. Dr. Marriott also advocates either the use of Trendelen- 
burg’s position on an operating table, or having the patient lying prone 
on a couch, with his head supported over the end. In these positions there 
is no danger that the regurgitation of fluid around the tube in the pharynx 
will fall into the trachea, which happens in unconscious cases when the 
cough reflex is absent. 

When the patient is in position his false teeth are taken out and if he is 
unconscious a mouth gag is inserted. The tube is lubricated and passed 
into the mouth, slight pressure on the tube as it reaches the posterior wall 
of the pharynx will direct it into the oesophagus; it Is then passed quickly 
on, until the mark on the tube ^20 inches from the end in the case of an 
adult and 10 inches for a child) is at the level of the lips — the tube is now 
in the stomach. 

Half a pint of lotion is now poured in, and siphoned back into a receiver 
— in a case of poisoning plain water is used — this specimen is kept for 
examination. Washing out of the stomach is then continued, using a pint 


135 



136 IRRIGATION, LAVAGE AND CATHETERIZATION 

at a time until the fluid begins to return clear and odourless. Anything 
up to two gallons may be required. 

When the treatment is over, the tube is withdrawn and either the mouth 
is cleansed or tlie patient given a mouth-wash. The soiled tube should be 
washed in tepid w ater, and boiled after use. If a nurse has performed this 
treatment, she w^ould be expected to make a report on the amount of 
lotion used, the state in which it was returned and the presence of any 
blood, mucus and bile, and the odour. It may be necessary to save all 
the fluid for the inspection of the doctor. 


HIGH COLONIC IRRIGATION 

In this treatment fluid is injected in fairly large quantities into the bowel. 
It is used in the treatment of colitis and diverticulitis, and in other cases 
in which toxaemia is marked and thought to be aggravated by absorption 
from the bow^el as, for example, in eclampsia. The fluids used include 
normal saline, plain warm water, a solution of potassium permanganate i 
grain to the gallon, and many otlier slightly antiseptic, and sometimes 
slightly mucilaginous, liquids may be ordered. At least 8 pints should be 
prepared and in many cases up to 20 may be used. The temperature of 
the fluid should never be above 100® F., and the nurse should work from 
the right side of the bed. 

The condition of the patient has to be taken into consideration, and 
this must be observed throughout the treatment, the pulse being taken 
before the treatment begins and again afterwards, and a comparison care- 
fully noted. 

Almost any apparatus suitable for rectal injection may be utilized. Some 
sisters use a tubing and funnel, others like a graduated 2-quart irrigation 
can. A soft rectal tube should be attached, for passage into the rectum. The 
container or pail for the returned fluid should also be graduated so that the 
nurse can always know how much fluid is for the moment lost — that is, 
how much is at any given moment in the patient's bowel. 

The treatment of colonic irrigation is divided into two parts, one de- 
scribed as iirigation and the second as lavage. 

Irrigation. The patient lies on his back in the dorsal }X)sition with his 
shoulders flat on the bed and a soft pillow under his head. Fluid is run 
through the apparatus first in order to expel air, and the rectal tube is 
then inserted carefully into the rectum, allowing a little fluid to precede it, 
in order to facilitate its passage. Up to 2 pints of fluid are allowed to run in, 
the nurse watching the patient C2u*efully for any signs of discomfort, paus- 
ing if she sees these, and then continuing. Not more than two pints should 
be lost with the patient in this position. The fluid should be very gently 
injected, having the can or funnel just above the level of the bed to ensure 
that the rate of flow is slow. The can is then lowered to the level of the 
floor, and the fluid allowed to run back into it. The can may be raised or 
lowered alternately to perform the process of irrigation; or, larger quanti- 
ties of fluid having been prepared, continuous irrigation, in and out, may 
be made into the bedside pail. When the irrigation process is complete 
the first fluid used is siphoned back. 

Lavage. For this, the patient lies first on his side, in the left lateral 
position, and one pint is slowly injected. He turns on to his right side, and 



HIGH COLONIC IRRIGATION 1 37 

this is repeated. He then slowly assumes the knee-chest position and a 
third pint is injected. He rests for a minute or two if he can — that is, if the 
discomfort is not too great — and is then allowed to evacuate his bowel 
of the 3 pints of fluid on a special bedpan capable of containing this 
quantity. 

If the patient is not capable of getting into the knee-chest position an 
alternative plan is to employ the left lateral, the dorsal and the right 
lateral positions in this order. 

The nurse carefully observes the general condition of the patient immedi- 
ately after the treatment, inspects the returned fluid, and reports the 
presence of undigested food, bile, blood, mucus, casts, worms or other 
foreign bodies, the colour and the odour of the fluid, and the occurrence 
of any pain, difficulty, or spasm during the procedure. Careful comparison 
should be made between the initial amount prepared and used, and the 
amount returned. If at any time during the procedure there should be any 
difficulty in returning the lost fluid, the nurse should elevate the irrigation 
can, run rapidly in about 4 or 5 ounces, equally rapidly lower the recep- 
tacle, when she will find that the fluid will begin to siphon back. 


CATHETERIZATION 

The act of catheterization taps the urinary bladder, and is carried out 
by means of a urethral catheter. 

Types of Catheters. Urethral catheters vary in length and shape for 
male and female patients. The female catheter is short and fairly straight, 
and is made of glass or metal. Male catheters are longer and curved, and 
they are usually made of metal or hard rubber. Metal ones are curved; 
some having a specially large curve are prostatic catheters, designed for 
use when the prostate gland is obstructing the passage of an ordinary 
catheter into the male bladder. The hard rubber catheters just mentioned 
are made of rubber composition or gum elastic. Examples of hard rubber 
catheters for tapping the male bladder include the ordinary^ straight 
gum elastic catheter, the coudi catheter which has a short curve at the tip, 
the bicoudi which has a double curve and the olive-headed catheter which has 
a bulbous portion immediately behind the tip. 

Soft rubber catheters have many uses, as for catheterizing the bladder, for 
the administration of rectal injections, and for nasal feeding. 

Self retaining catheters may be employed for keeping the bladder empty; 
these have bulbous ends which prevent the catheter from slipping out; 
in order to insert the catheter a special director is employed which tem- 
porarily straightens out the end. A self-retaining suprapubic catheter is 
passed into the bladder through a wound in the lower part of the anterior 
abdominal wall, above the pubes. 

Ureteric catheters are fine instruments, long enough to be passed along the 
ureter into the pelvis of the kidney, in order to collect a specimen of 
urine from one side only, or for the injection of fluid into the renal pelvis. 
The method of application is described on p. 140. 

A uterine catheter is made of soft rubber and has graduated markings upon 
it to indicate the distance the catheter is passed into the uterus. For the 
introduction of a uterine catheter, the anterior vaginal wall is retracted 
and a special pair of introducing forceps is employed; the rubber catheter 



138 IRRIGATION, LAVAGE AND CATHETERIZATION 

is clamped between the blades of this instrument and guided into the 
uterus. This catheter is used for the introduction of glycerine in the 
method of ti'eatment described by the late Dr. Remington Hobbs for 
uterine drainage in cases of puerperal sepsis. 

An intratracheal catheter is employed for the introduction of anaesthetics 
by this route. 

A eustachian catheter is used to test the patency of the eustachian tubes; 
or to enable inflation of the tube to be carried out when obstruction is 
complained of. (For types of catheters sec also figs 54 and 56, pp. 170 and 
172.) 

Female Catheterization, The articles required for this procedure 
(see fig. 55, p. 1 71) include two sterile catheters — two being supplied in 
case one should be soiled in a first attempt at passing the catheter. 

Some mild antiseptic lotion and sterile swabs will be required for cleansing 
the vulva and some stronger lotion for cleansing the hands of the nurses. 

Three receivers ^\dll be required, and one of these should be sterile as it 
is needed to collect the urine and a sterile specimen may be wanted. The 
other two are required for the soiled swabs and the used catheter. 

A sterile measure should be provided for the urine and a sterile specimen 
glass and test tubes. 

Position of the patient. If possible the patient should lie on her back, 
with one or two pillows supporting her head and shoulders; her thighs 
should be flexed and abducted. She can be made very comfortable in 
this position if her feet are placed flat on the bed. The bed should be 
screened; a good light must be provided and it is advisable to place a 
hot water bottle in the bed. 

Procedure. The patient is lying in the position described and the bed- 
clothes are divided so that some are used to cover the upper part of her 
body and others cover the legs and thighs. So arranged it is easy for the 
nurse to separate these by manipulating the movement of them with her 
elbows (after she has scrubbed up) should she have to work alone, without 
an assistant. 

The nurse should w^ork from the righthand side of the bed — unless she 
is lefthanded. She should place sterile towels above and below the pubes and 
then separate the external labial folds with the fingers of her left hand, 
holding them apart until the catheterization is over. The vulva should be 
carefully cleansed, paying special attention to cleansing the vestibule 
and urethral orifice. The latter should be inspected to see that it is normal 
in size and character. 

The sterile receiver should then be placed on a mackintosh or towel on 
the bed, between the patient’s legs and ready to receive the urine. The 
nurse should pick a catheter out of the lotion in which it is lying, shake it 
gently to free it of moisture, hold it about an inch from the open end, and 
if it is a glass catheter, inspect it carefully to see that it is not cracked or 
broken. It should be gently inserted into the opening of the urethra, with- 
out having touched any other part. The nurse should notice whether the 
patient is relaxed or rigid; if she is holding herself stiffly, this may be over- 
come by asking her to open her mouth slightly and breathe through it; 
concentrating on this, she may relax. If there is any difficulty in passing 
the catheter, it is important that force should not be used; any real diffi- 
culty experienced would necessitate the use of a rubber, not a glass, 



CATHETERIZATION 


139 

catheter. In a normal case the catheter can be passed with ease, and the 
urine will begin to flow into the receiver provided for this purpose; it should 
be held steadily and, when urine ceases to flow, if the catheter is with- 
drawn slightly it may tap urine which is at a lower level in the bladder. 

Finally, when urine has ceased to flow, the catheter is gently withdrawn; 
if the nurse places a finger over the open end, she will find she can with- 
draw the catheter without spilling any drops of urine; when she removes 
this finger and inverts the catheter, it will empty itself as its contents will 
fall by force of gravity. 

The catheter should be carefully inspected again, to see that it is still 
intact. It would be a serious complication if a catheter were to be broken 
in the urethra, as retention of small pieces of glass might cause serious 
injury. A nurse should never attempt to remove this, should it happen; 
she ought to send for a doctor and get ready some lotion and swabs and 
long narrow forceps which he may require to use. 

After catheterization the patient is dried, the bed remade and the 
patient left comfortable; she should be given a hot water bottle and a 
warm drink and be tucked up in bed. 

Report of the time of catheterization, the amount of urine obtained; any 
difficulty experienced or pain caused and the character of the urine with 
notes on the presence of any abnormality should be made immediately, 
before these points are forgotten, and the urine should either be tested by 
the nurse or sent to the laboratory for examination. 

Precautions. The strictest asepsis should be maintained and carried 
out for the purpose of catheterization, in order to prevent the entry of 
micro-organisms into the bladder which would give rise to cystitis. 

A nurse should realize that patients who need regular catheterization 
do get cystitis, when there can be no possible reflection on the surgical 
technique practised, and that this probably occurs because the tone of the 
bladder is lowered cither owing to frequent retention or, in some cases, as 
when the prostate gland is enlarged in men, or after the operation of 
radical hysterectomy in women, because the bladder is never properly 
emptied and because the residual urine, how ever small the quantity may 
be, acts as an irritant. 

The use of a glass or metal catheter is contraindicated in midwifery 
practice, in the case of very nervous patients and children, and after opera- 
tions on the perineum. A soft rubber catheter should be employed in these 
cases. 

Whenever the bladder is very seriously distended and the condition has 
persisted for some time, it is inadvisable to empty it rapidly, by catheteri- 
zation. It is better to draw off the urine very slowly, and even to close the 
end of the catheter by a spigot and allow two intervals of from 10 to 30 
minutes to elapse before completely emptying the bladder. 

When a rigor occurs soon after a catheter has been passed — this is de- 
scribed as a catheter reaction — the patient should be put to bed, warmly 
wrapped up and given hot lemon drinks. A doctor may consider it neces- 
sary to order some quinine. The patient’s temperature should be taken at 
frequent intervals of 15-30 minutes as long as it continues to rise. 



142 IRRIGATION, LAVAGE AND CATHETERIZATION 

The clamp is then adjusted to permit of the flow of lotion into the 
bladder at the rate required; but when from 6 to lo ounces have been 
passed in the flow is arrested, and the bladder allowed to empty, by releas- 
ing the clamp on the rubber tubing which hangs over the pail, below the 
Y glass connexion. The irrigation is continued, either until a given amount 
of fluid has been used or until tlie returned fluid is quite clear and free 
from any odour. If treatment is continuous the catheter is allowed to 
remain in the bladder; when treatment is intermittent the catheter may 
be removed. The patient should have a hot drink and be warmly wrapped 
up after bladder irrigation. 

Tidal Drainage of the Bladder. Dr. Munro of Boston, U.S.A., intro- 
duced tidal bladder drainage. The Laurie-Nathan apparatus shown in fig. 
15 is a recent modification of Munro’s method. The apparatus is first 
assembled and then boiled. The flask filled with warm lotion is placed on 
the stand at the bedside, the screw clip being closed; the siphon tube (C) is 
fixed at the level shown. A catheter is passed and a spigot inserted. The 
screw clip (A) is then loosened and the tubing (B) and (D) filled with 
fluid to expel all air, the spigot is removed from the catheter and the tube 
(D) is connected to the catheter. Great care must be taken to exclude air 
or the apparatus will not function. 

The bladder is distended to a certain level which is determined by the 
height to which the siphon is fixed above the level of the symphysis pubis — 
in the illustration given this is shown as about 7 inches. The lotion is 



Fig. 15. — Laurie-Nathan’s Apparatus for Automatic Tidal Dralnaoe of Bladder. 

Ht is important to assemble the apparatus with the tubing of the sizes and lengths given 
below.) 

A. Four inches of rubber tubing, J inch diameter. 

B. Sixteen inches of tubing of flic same bore. 

C. Two yards of pressure tubing, i inch diameter, 

D. One yard of pressure tubing of the same bore. 

The dottcci line represents the level of the symphysis pubis which is taken as approxi- 
mately the level of the catheter in the bladder. 



IRRIGATION OF THE BLADDER 1 43 

graduated to drip at 6o drops per minute so that the bladder fills slowly, 
and when pressure within the bladder reaches the level of the siphon 
tube the bladder automatically empties. It is the nurse’s duty to see that 
the flask is not allowed to run dry, that the free end of the siphon tube is 
always above the fluid in the collecting bucket, the level at which the 
surgeon arranges the siphon tube is not altered, and that the glass Y con- 
nexion hangs free and is not tucked in with the bed clothes, and that the 
tubing does not get kinked. The amount of fluid added to the reservoir 
and emptied from the bucket must be recorded. The catheter is changed 
every few days. Great care must be taken not to permit air to enter the 
apparatus when changing the catheter. 

Duke’s apparatus (see fig. 14) is sometimes alternatively employed. 
By this means the bladder is kept empty and can be irrigated at intervals. 
The catheter constantly drains the bladder. To flush the bladder — close 
the clamp below^ the Y connexion and release the clamp above the drip 
bulb, then allow half to one pint of fluid to pass into the bladder. Now 
close the clamp alx)vc the drip bulb and release the clamp below the Y 
connexion and the bladder will empty. By this means intermittent flushing 
of the bladder can be carried out at intervals. 

VAGINAL DOUCHING 

Irrigation of the vaginal canal is usually described as douching. It is per- 
formed in order to cleanse the vagina when a woman is wearing a pessary 
and as treatment in some cases of discharge and before an operation on the 
lower part of the female genital tract. Vaginal douching is also employed 
in the treatment of inflammatoiy conditions of tlie vagina, cervix, ovaries 
and tubes and in the emergency treatment of severe uterine bleeding. 

The solution used varies — many mild antiseptics are employed, including 
boracic lotion, Condy’s fluid, lysol and iodine in the strength of half a 
drachm to the pint of water, perchloride of mercury 1/5,000 and flavine 
I /4,ooo 

For cleansing purpo.scs the lotion should be warm; in the treatment of 
indammatory conditions it should be hot — about loo"^ F.; and for the 
treatment of bleeding it is used very hot, up to no'’ F. 

The condition of the external genitalia should be inspected carefully 
before a hot douche is given; it may be necessary to smear the parts with a 
lubricant in order to protect them from injuiy by the hot solution. 

rhe articles required (see fig, 59, p. 1 74) include a mackintosh and 
towel to protect the bed. 

Sterile towels to place over the bedclothing, which is divided in the 
middle. 

Two glass douche nozzles, an irrigation apparatus or douche can with 
tubing and clamp, sufficient lotion and a lotion thermometer. 

Lotion and swabs to cleanse the vulval region and a bowl for soiled 
^vvabs and a receiver in which the douche nozzle will be placed after use. 
A douche pan and cover. 

Method of giving a douche. As a rule the patient lies on her back 
the legs drawn up and knees separated (but a douche can be given 
with equal convenience to a woman lying 011 her side) . The bedclothes are 



144 IRRIGATION, LAVAGE AND CATHETERIZATION 

divided and separated so that the patient and her legs arc covered and only 
the vulval region is exposed. This region is covered by a sterile towel. The 
patient is placed on the pan. The nurse washes her arms and hands, re- 
moves the towel over the vulva with forceps to avoid soiling her hands — as 
the patient may have touched this towel — she then separates the labia and 
cleanses the vulva with swabs and lotion, inspects the glass nozzle to see 
that it is intact, allows some lotion to flow through from the irrigation can 
and inserts the nozzle into the vaginal canal. She should move the nozzle 
about in order to irrigate the walls and vault of the vagina. 

When the treatment is over, the glass nozzle is removed and inspected 
carefully to see that it has not been broken during the treatment. If the 
patient can sit up, she may do so for a few' minutes, as the erect position 
favours more complete drainage of the vagina. The toilet of the vulva is 
completed by drying both the lower part of the vagina and the external 
parts. The bed is rearranged and the patient made comfortable. 

The lotion used should be inspected and any abnormalities noted and 
reported. 



'i^LH^E>rAMuiimoM 



\u.. I h. \t'i I'fjrt 2’~f . A; IJr(iri( torch. I li<' insiruincnls shown arc tvso 
\\\ cs oi toiiT.iK (Icpicssor. and tuo ]>air.s of loiacps toi- sw ai )f )inii the dir« at, 
• I nc( cssa 1 \ . 



t7. sre pai^e -27. A ])r(>ctns(op<’ is shown in th(" nheidh* ()rtl\(‘ ]:)i( ture; 
>*ihrica!it is siip])li<‘d for this. The doctor may nerd ^lov<\s or a fint^(‘r stall. 

drawshf'rt at the left is for (ovriinK the buttocks when the bedclothes 
< folded back. An enamel bowl is supplied for used swabs and a receiver 
oiled gloves or finger stall. 






Fig. 1 8 . — see page 45. The articles required include those for washing the 
patient: warmed bath blankets, bath, face, back towel, and two washing 
cloths. Tow for the initial swabbing of genitals. Soap, nail-brush, nail 
scissors and a receiver for nail parings and used swabs. Powder for l>ody 
creases and back. All articles required for bathing, cleansing of the mouth, 
attention to the nails and treatment of pressure points should be prepared. 
Glean warm clothing for the patient should be ready to hand. 



brush and comb. 




20. .scf f)a^€ 47. I'hc position of the Nurs{‘\s hands when lowrrini; 
baby into his bath. 



Fk;, 21 . — ^ee pa^e 47. Methtxl of holding a baby when washing the head. 




Mouth Wash 

PeccurcR ... lowcL 



I'lf.. jj. .sec /idi^r 48. Two pairs of tor(t4).s art' su]>[>lircl, artt'ry forceps or 
tin'ssini; for('c[)s to hold the swabs wht'ii ch'ansing tht* mouth, and dissrc tini> 
foK t-ps to rciiHA’c the used swab so that it is not handh'd by lh<‘ tinc^crs. 
Orange sticks arc used to remove particles IVom between th(' teeth. .\ ( hoice 
(»1 lubricant and antiseptic is provided in this ('xunplc. 




^ . 24.^ see page 50. 'Fhc small loothconib is used wet when combing 

head for the removal of lice. In this example carbolic lotion i/l-o is 
' “ddoyed. Dry w^ool swabs are provided for cleaning the comb, n inoving 
^■ dr and lice, if any. 



150 



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Routine Treatment 
Prevention « Bedsores 




I*iG. 25 . — see page 53. I'or rcnuine tmilnicnt of pressure points either soft 
tow or a washing cloth kept solely for this purpose should be supplied for 
washing the skin. 



26 . — see page 57. Receptacles for Collection of Specimens. 
i 2 — urine specimen glasses; 3 — flask for catheter specimen of urine; 
faeces; 5 and 6 — sterile test tube and flask for blood, fluid, stomach 
etc.; 7 and 8™stcrilc bottles for specimens of blocKl (one con- 
'^iniing potassium oxalate); 9 — sterile swab; 10— glass containing culture 
iiedia; 1 1 — for sp>ecimcn of sputum; 12 — f ocket sputum flask. 



a 






Pu;. 2'j,~.sct' /uti^f 77. Ci^lAN(;l^ (; nil-. Ho r i om Sm.i. 1 whi.n ihi, 

M.'W BK Ti RNFi) ON T(> ONE OR HO I H SiDi-N. TIk' short markiiiiosh and (iiaw 
ihcrt art- hcin^ ( at th<‘ saiiK* time. 


V'^ l-w 








I'Ki. 2H.- .see paffe 77. CuANfaNc; ihe HorroM Sheet when iiie Patient 

GAN BE LIFTED BUI MAY NOT BE TURNED ON Ills SiDE. "I hc short mackintosh 
and drawshcft have been removed. 






Fig. 32 . — see pa^e 8H. Modification of tuf: iT:Fr-HAND Lateral Position. 
Modilication ot' the left lateral position, as used for vaginal examination. 



Fig. 33 . — see pa^e 89. Position used for Postural Drainage of Lungs, 
Nelson’s bed is shown in the illustration. 


i5(') 




1'k,. ^^4.-" pane ()(). PicrcN of llaniK'l, blanket, lint (►r any 
other absorbent material may be used as a ni(‘(iieal 
fomentation. 



So- — 9^*- 

Mkthod or CoTTiNc; Materials for I'omen i ation. 

(A) Note that the lint is double; the jaconet is one inch 
larger and the wool larger again than the jaconet. 

(B) MethcKl of cutting a finger fomentation. 



^•"V.\GICAL FmCNTATION 



I'lG. ’]i).— S€c pa^c <)2. Instruments: Scissors; sinus, dissecting, dressinc; 
and artery (orcej->s, probe, sterile towels and dressiness; lotion and 
thermometer. 'I'he fonK'ntalion may hr boiled in a saiK'cjian or a stiTil'* 
wringer and lint may be us(‘d. 


LinseeoPoultice 



Fic;. 3*7 . — see page q6. All articles arc warm, a small bottle of olive oil 
is standing ready in hot water, the spatula is in hot water, plates and 
towel, wool and binder arc warm and the delf porringer supplied for 
mixing the poultice contains hot water so that it may be as warm as 
possible. 


I5B 



Fig. ^n.—see page 106. Appijcation of Leech. (A) Lr(Th in upper J of 
lest tube, the lower 5 being hlled with cotton wool. (B) a square of linen 
for handling leech if necessary. (C) a piece of lint having a hole cut in it, 
through which the leech is apf)lied (sec above). (D) warm milk. (E) salt. 
(F) method of applying a pressure dressing in order to arrest bleeding, after 
removal of leech, if necessary. 


Blistering 



Fio. 39. — see page 107. Appi.iCA'noN of Blistering Agent. (A) Blistering 
fluid. (B) glass rods. (C<) olive oil. (D) method of covering blistered area 
with guttapercha tissue and (E) metht^ of preparing a ‘gate of strapping’ 
with which to cover a dressing after removal of the raised epidermis when 
the blister has risen. In addition articles for cleansing the skin, before 
blistering, are provided. 



159 



I'ip. 40. — seepage 109. C.vvvisg. 

(A) Clupping glasses. (B) one example of Bier’s suction cups. (C) spirit 
lamp. (L)) a small quantity of methylated .spirit in a gallipot. (K) squares 
of blotting [)aper. (V) forceps for handling the lighted blotting paper. 
Vaseline is provided to smear tlic edges of the cups. 



1 10. 41. — see page 93. The bowl and spoon arc supplied to mix chopped 
ice and salt together in order to make a better freezing mixture. 









i6i 





I ^2 



Fig. 44 . — seepage 121. Tf.pid Sponginc;. 

Upper Shegf. Clinical thermometer. Howls for water, bath 
thermometer and sponges. Cold compress for patient’s 
forehead. Feeder containing drink. S imulant. 

Lower Shei.f. Bath sheets, hot water lx)ttlcs and articles 
for the treatment of back and other pressure points. 

A jug of cold water. 


163 



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i66 



Fig. 47. — seepage 12B. Articles for givinc; an Enema. 

Irrigation can, tubing and rubber catheter. Flatus tube. Swabs. Lubricant, 
Soap solution. Thermometer. 



Fig. 4H . — See page 12B. In some cases Higginson's syringe is ased for giving 
an enema but when this Ls employed a soft rectal tube must be attached to 
the hard bone nozzle. 






167 



SINKER 



FLATUS TUBE^ 





Fk;, 49. sr« 129. I'LATiis l iiBi:. 

A length ol rubbc'r tubing which carries a metal sinker is attached. 
The sinker (alternalivt ly a small funnel may be employed) serves 
to keep the free end of tiie tubing immersed in a basin of lotion so 
that the passage r>f flatus bubbling through the lotion can be noted. 


Ik ccTAL Saline 



Fk;. 50 . — see page 132. (A) Catheter, tubing and funnel. (B) short 
rectal tube which is passed before the saline is given, so that flatus 
may be expelled. Brown wool swabs arc provided to cleanse the 
anus and a receiver i Cl for the used swabs. A lubricant may be 
needed for the rectal tnlx' and rectal catheter. The prepared 
saline is standing in water. A lotion thermometer is provided. 



. Fk;. 51 . — seepage 130, 

Syringes for Administration of a Glycerine Enema. 

When a mixture of glycerine and warm water is employed a rectal 
catheter is used as in illustration Fig. 50, p. 167. 



Fig. 52 . — seepage 134. 

Articles for the Administration of a Si ppository. 

A flatus tube should be passed before inserting a suppository which is 
to be retained. 



*69 



Fi<;. .sft’ 

AwricrEs for (iAsruir, LAVA(ii:. 

Uffer Shelf. Slonuirh lub<^ t JaqiKs's pattern), lubri- 
cant, mouth gaiT and tongue I'orceps, loticHi and thcr- 
inoiiK'ter. 

Lower Shelf, Mac kintosh and towel, receiver in case 
ol \'(miit and for used lube, articles for cleaning the 
mouth. Pail for used lotion. 


170 





‘4 


Fig. 54 . — see page 137. Urethral catheters shown are (A) and 
(B) for female, metal and glass. The short ones arc Kidd’s 
pattern. (C) prostatic catheter. (D) rubber, (E) Harris’s, and 
(F) whistletip patterns. (G) composition, olive-headed, 
(H) coude, and ( 1 ) bicoude patterns. ( J) Malecot’s tw'o-winged 
pattern (this type is also used for suprapubic drainage). 
Suprapubic catheters shown (i) Dc Pezzer’s and (2) JoH’s 
patterns. 

Intratracheal (i) silk web and {2) rubber MagilFs pattern are 
employed for the introduction of anaesthetics by this route. 

A uterine catheter is a soft rubber catheter with a terminal eye 
used for injection of substances into the uterus. 

Ureteric catheters are passed along the ureters to the pelvis of 
the kidney, see p. 140. 

Eustachian catheters arc passed into the custachian tube to test 
its patency in an extensive examination of the car. 





55- — *3^- the Upper Sheef of the 
wagon two rubber and two glass (female) cathe- 
ters are in a small tray, T he sterile receiv'er (on 
the right) is for collection of the urine. Swabs and 
lotion are needed for cleansing the vulva and 
urethral orifice. 

On the UowER Sheef a variety of specimen flasks 
and pathological department labels are provided. 




172 


Sel^^ritaining CAfftWeRS 1 




I IG. f)6.— pai^c 137. 

1. Malecot’s catheter, without and with introducer. 

2. De Pezzer's catheter, also with introducer. 

3. Harris's rubber catheter and metal introducer. 



Fig. 57 . — see page 143. Duke’s apparatus 
consists of irrigation can, tubing, Y- 
shaped glass connexion, catheter and 
collecting bottle. Note the position of the 
clamps. 

To fill the bladder relca.se the clamp 
Viclow the reservoir of fluid and close the 
outlet by closing the clamp below the 
Y-connection. 

To empty the bladder close the clamp 
below the reservoir and release the 
clamp Ijelow the Y-connection. {See 
also pp. 140-3.) 


tasErnaassa 



F u ; , 58 . - st e j>age 1^0. 

Articles for Bladder Irki(;ation. 

( svY also Fig. 14, /l 141) 

The glass funiul and rubber tubing and connexion 
for catheter arc ready in the porringer to the h'ft 
of the lop of the wagon. C^^atheters and sterile towels 
are on the right. Swabs and small porringer of lotion 
are provided for cleansing urethral orifice. A ther- 
mometer is provided for testing the heal of the lotion 
used. 

The sterile receiver on the bottom of the wagon is for 
the reception of the urine which is first drawn ofT, 
in ca.se a specimen is required. 



*74 



Fig. 59 . — see pat^e 143. 

Akticles for Vaginal Douching. 

Upper help. (A) Glass douche nozzles. (B) 
Douche can, luoiug ana clanijl. Lotion, ther- 
mometer, measure and swabs. 

Lower Shelf. Mackintosh and towel, douche 
pan and cover, Iwwl and receiver for soiled swabs 
and used douche nozzle. 


*75 



Tig. bo. page 193. Articles for Artimciai. Feeding. 

In nasal frodiiig articles to cleanse and lubricate the nostrils arc required 
swabs, lubricant and forceps. Note the small size ol a nasal catheter as 
rompar(*d with an cH-sophageal tube. In both nasal and oesophap^eal feeding 
the fluid given should be warm. After oesophageal feeding the patient 
should either be given a mouth-wash or have his mouth cleaned. 



I'lG. 61. — see page 197. Articles for Subcutaneoi s Infusion of Fluid. 
Three types of apparatus are shown for the administration of subcutaneous 
saline. (A) graduated funnel, tubing, Y connexion and two needles — the 
upper of the two needles is fixed in position by means of a strip of clastoplast 
to prevent its slipping out of the skin. (B) apparatus for continuous infusion 
fitted with rubber tubing clamp, drip bulb, tubing and two needles. 
(C) Souttar’s vacuum Bask. 

In addition articles arc needed for cleansing the skin, warm wool to cover 
the part undergoing infusion, and scissors to cut the strips of clastoplast. 



176 



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177 



Fu;. ir].— see pa{>t' 198. 
Appau ATI'S FOR 1 ’akin(; Blood. 


I-'k;. sff 41 nnd D)8. 

Si‘i 1 v( iM( )\] A\( )vn: ILK . 


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iTii. bfv .^o fmjat 198. 
Apparatts for C»ivin(; Blood. 

( I ) and (2) bottles for blocxi. (3) Rub- 
ber bung through which glass tubes 
pass. (4) tubing tap attached to 
Laurie’s drip bulb; by means of a 
syringe air collecting in the tubing 
can Vje removed. (5) glass window for 
noting level of air in lube. (6) Kaufl'- 
man’s syringe for giving blood. 




178 


Fig. 66 . — see page 203. 
Upper Shelf. Loc:aI anaes- 
thetic, hypodermic syringe, 
exploring syringe, aspirator, 
sterile towls and swqbs. 
Specimen tubes and flask. 
(Tlie method of testing the 
aspirator is de^sicribed on 
page 203.) 

On the Lower Shelf is 
found articles for prepara- 
tion of the skin. 

A stimulant in case the 
patient needs one. 

Basin and receiver for soiled 
swabs and used irLstrurnents. 



Fig. 67. — see page 203. 

Potain’s Aspirator. 

(i) Pump. (2) Aspirating 
bottle. (3 & 4) Taps con- 
trolling inlets. (5) Con- 
nexion between tube and 
needle. (6) Needle or can- 
nula. (7 & 8) Trocars to fit 
hollow cannula. (9) Ckillar 
or trocar to fit cannula. 



>79 


u5LI^<iJi!i21II 



Fic:. 68. — see page 205. 
Articles for 
Abdominal Paracentesis. 
Upper Shelf. Instruments 
(Fig. 69). Local anaesthetic, 
articles for cleansing skin, 
stimulant. 

Lower Urinal. 

Catheters in case required. 
Sterile flasks for specimens. 
Receiver. Abdominal binder 
for use when required. 

When a large trocar is em- 
ployed a pail should be pro- 
vided as the fluid will flow 
quickly. But when tiny tro- 
cars are used, the fluid will 
drain away more slowly, 
and may be collected in a 
receiver placed in the bed, 
or be permitted to drain into 
cotton wool which will be 
changed as it becomes satur- 
ated with fluid. 



Fici, (>9 - - >str 205“6. 

Instri^ments for Tapping. 
(A) Southey's trocar and can- 
nula. When this is used a tiny 
incision may have to be made 
for which scal|X‘l, dissecting 
forceps and a stitch may he 
required. 



i8o 



Fig. 70 . — see page 206. 

ArTIC’.LKS K)R LiMRAR Pi NCTIRE AND I NTRATHKCAI- INJECTION OF SeRI'M. 

A) I'.xploring syringe and Barker's needle. (B) Hy[KKiennic: syringe and local 
anaesthetic. ((1) Phial of serum in water at 99 deg. F. {!)) .\ stimulant in case of 
need. Sterile towels and dressings, collcKlion and strapping. Articles for cleansing 
the skin. Sterile specimen tubes and flasks i ur also Fig. 75, w'hcre Greenfield’s 
manometer for measuring the pressure of th<' reiebro-s|)inal fluid is shown). 


i8i 




Tui. 71 . — see pa^e 209. 

Bakium Meal Examination of Stomach Showing Ulcer Crater. 
The dotted line represents the normal outline of the lesser curv^ature. 
Note also the constriction of the stomach, opposite the ulcer. 



i 62 



Fi(i. 72 . — see f)a{ie 210. 

Barium Meal Examination of Colon Showinc; Filling Defect in 
Caecum. The dotted line represents the normal outline of the 
caecum. The alteration in the contour of the caecum is due, in this 
case, to carcinoma. 



183 







Fu;. 73 . — sec page 210, 

LipionoL Examination of Bronchial Tree. 

(A) indicatt^ position of right bronchus dividing into eparlcrial and 
hypartcrial bronchi. (B) shows distribution of lipicxiol in normal 
alveoli and (C) bronchiectasis in lower IoIk^ due to dilatation. 


1 84 



Fi(.. 74. .stf ffagr 210. HYsrhK()-sALriN(;()(;RAi‘HV. 

Examination ot llu* patciK y of ihr fallopian lubf s. Ehr opaque medium used 
is lipiodoL Fhe shape of iIh' uU'i us ran Ik: seen and ihe fine fallopian IuIk: on 
the left. 'I'he opaque medium shows the outline of the lube and the sha}X‘ of 
its fimbriated end. Sui)sequent examination would show that the lipiodol 
had dripped from the tulx* into the p<‘lvic ravity. In this patient the right 
tulx: is not patent, it may l>e absent. The examination proves that only one 
tube funrtions. 





Fig. see page 2 10 , Encephalogram. 

Showing the aritcrior and posterior horns of the lateral ventricles 
filled with air. 



187 



Fic;. 77.-'- sec '2 1 1 . 

C^HOLECYSTOGRAM SlIOWINCi GaLGSTONF.S IN A DyI -I-II IH) 
Gai.l Bladi>er. 

Thr gall bladder is outlined, the positions of the gall sloiu s 
indicated and the psoas muscU* is outlined. 



m 




Kh;. y {). -ser page 2 1 ^. Uroski-kctan Examination. 

The outline of pelves, eaiiees and ureters is shown by the dye. Upjx 
middle and lower c alic es ran be distinellv seen. 



Test Meal 



Fig. 82 . — see pages 213-7. 

A Ryle’s tube and 20 c.c. syringe are in the porringer on the front of the tray. 
Glycerine is provided to lubricate the tulx*. Specially large flasks are provided 
for the resting juice and residual fluid and a number of test tulx*s labelled 
I, 2, etc., for the specimens of stomach content withdrawn every 10 to 13 
minutes ^sce above). 



Fio. 83. — Ryle’s Tube. 
Note the bulbous, slightly 
weighted, end of the tube. 



Chapter ii 

Artificial Feeding and the Administration of Fluid 
and Blood Transfusion 

Methods of artificial feeding — Channels for the administration of fluid — Blood trans- 
fusion: direct and continuous — The grouping of blood, 

ARTIFICIAL FEEDING 

F ood may be introduced into the body in the following ways — by means 
of an oesophageal tube passed through the mouth, by the nose in nasal 
feeding, and by the rectum in rectal feeding. It may also be adminis- 
tered by means of openings artificially made as when food is introduced 
into the oesophagus by ocsophagotomy, into the stomach by gastrostomy, 
and into the small intestine by duodenostomy or jejunostomy. 

General rules for consideration which will be found applicable in 
most cases. Only liquid food can be used. The temperature of the food 
should be between 95° and 100° F. The amount given must be measured 
and recorded, and in most cases the liquid should be strained, otherwise 
the tube through which it is passed may be blocked. 

When the patient is conscious and capable of knowing what is being 
carried out, the treatment should be explained to him and the character of 
the feeding described. If the patient is delirious or difficult to mgmage help 
may be required to steady him during the administration of the feeding. 
In the case of a very young child it is wise to wrap him in a blanket so 
that his arms cannot be unexpectedly used to pull the tube away, should 
he suddenly become frightened. 

Any medicines or stimulants the patient may be having should be ad- 
ministered cither before or after the feeding, to save passing the tube a 
great number of times. 

The apparatus should always be clean, moist and warm; the patient 
must be comfortably arranged, the nurse being very gentle and no force 
ever being used. 

NASAL FEEDING 

For nasal feeding a fine catheter is passed through the nose and on into 
the oesophagus for about 4--6 inches. The article^ needed (see fig. 60, 
P* 1 75) — a mackintosh or towel to protect the bed. 

A fine rubber catheter^ no. 3 or no. 4, should be attached by a fine glass 
connexion to a short length of rubber tubing, which has a glass funnel 
attached at its other end. This should be boiled and placed in warm water, 
ready at the bedside. A rubber tubing clamp may be useful, but most 
nurses learn to control the rate of flow by pressure of their fingers on the 
rubber tubing. 

A non-irritating lubricant^ such as liquid paraffin, is usually supplied, 
cither to apply to the end of the catheter or to cleanse the interior of the 
nos^il. As the catheter is moist it will be slippery enough, provided the 
cavity through which it is to pass is lubricat^. 

1 X93 



194 ARTIFICIAL FEEDING 

Saline swabs arc better for cleansing the nose than boracic, as the latter 
is astringent and slightly irritating. Dty swabs should be supplied in order 
to dry the edges of die nostril when the tube is removed after the feeding 
has been given. 

The quantity of food to be given should be warmed and standing ready 
in the measure in a bowl of water; a lotion thermometer should be provided in 
order to ascertain the temperature of the, feeding. 

Method. When possible have the patient' propped up, but the feed can 
be given in any ordinary position. Having placed the mackintosh and 
towel in position to protect the bed in case of accident, cleanse the nostril 
that is to be used, choosing the one seen to provide the clearest passage, 
lubricate it and pass the tube gently but quickly, some 6 or 8 inches, pass- 
ing it in a backward, not an upward direction. 

See that it has not come forward and curled up in the mouth, listen with 
the ear against the funnel as the movement of air may be heard if the tube 
is in the trachea. Look at the patient and see if he is at all cyanosed, 
whether he is coughing, and whether he appears to be quite comfortable. 
If in doubt withdraw the tube and try again. 

When satisfied that the tube is in the oesophagus, pour a little sterile 
water into it and allow this to trickle down, checking the flow by constrict- 
ing the tubing — the absence of distress will confirm the fact that the tube 
is not in the trachea. Give the feeding, then pour a little water down to 
clear the tube, pinch the tube close up to the nostril and withdraw it 
rapidly. Inspect the nostril and dry it or lubricate it if necessary. 

Some sisters recommend that a nurse should ask the doctor in charge of 
the case to be present when giving the first nasal feeding to any patient, 
but this only applies to the inexperienced. Sometimes the tube is left in, 
and it should then be clamped at the end of the feeding, and fastened up 
on to the side of the temple by means of a piece of strapping. 


OESOPHAGEAL FEEDING 

The articles (see also fig. 6o, p. 1 75) which will be required arc similar 
to those for nasal feeding. It is necessary to protect the bed, strain and 
warm the feeding; the mouth should be cleaned and a lubricant which is 
pleasant to taste should be provided for applying to the end of the tube; 
glycerine and lemon is excellent for this purpose. 

The apparatus consists of a Jaques’s oesophageal feeding tube, with a 
funnel attached. A mouth gag will be needed if the patient is obstreperous, 
and since he may feel sick, or be sick, a vomit bowl and towel should be 
provided. Articles for cleansing the mouth when the tube is withdrawn 
should be at hand. 

Method, The patient should be sitting up if possible, supported by 
pillows. The mackintosh and towel are arranged around his neck and 
under his chin, and he may be permitted to hold a receiver or vomit bowl 
if he is convinced he will feel sick. The tube is lubricated and passed gently 
over the tongue, and, putting it in at the corner of the mouth, it is pa^ed 
to the pharynx; slight pressure on the tube will deflect it and cause it to 
pass into the pharynx without impinging on the posterior wall of the 
fauces, and, the patient being asked to swallow, the tube k easily guided 



OESOPHAOBAt EEBOINO 1 95 

into the oesophagus. There is a mark on the tube and, when this is near the 
lips, the tube s^uld be in the stomach. 

The feeding is gently poured into the funnel and runs along the tube 
into the stomach. When all has been passed, a small quantity of water 
may be given, in order to leave the tube clear of fluid food. The nurse 
should then compress the tube and quickly withdraw it. The patient 
may rinse out his mouth for himself or else the nurse may clean it for 
him. 

As a rule from a half to one pint is given at a time and a patient on oeso- 
phageal feeding b usually fed every 4 hours. 


RECTAL FEEDING 

The apparatus required for rectal feeding is the same as that used when 
salines arc administered by this route (see p. 196 and fig. 50, p. 167.) 


OESOPHAOOTOMY, GASTROSTOMY AND 
DUODENOSTOMY FEEDING 

Artificial feedings by meaiu of openings made into the oesophagus, 
stomach or duodenum have certain points in common and the general 
principles of feeding by these methods can therefore be considered collec- 
tively. 

If the tube has been left in the wound, or an opening made, the apparatus re- 
quired consists of a glass connexion which can be attached to this and a 
short length of rubber tubing and funnel through which fluid food can be 
poured into the stomach. The apparatus should be boiled and placed 
ready in warm water. The food must be strained; a litde sterile or plain 
water should be supplied to pour in first, in order to test the patency of the 
tube; a little water is also used to clear the tube after the feeding. The bed 
should be protected. 

Method. As a rule there is a surgical dressing around the tube in order 
to protect the skin sutures which have been inserted to approximate the 
edges of the wound. It is advisable to arrange for the tube to pass through 
this dressing so that it need not be changed every time the patient is fed. 
The distal end of the tube should be closed by means of a clamp or spigot, 
and the tube may be attached to the exterior of the dressing, by means of 
a safety pin binding it down to the bandage. It should be covered with a 
towel. 

On arrival at the bedside the bedclothes should be protected, the tubing 
liberated and the spigot removed, and the glass connexion is then attached 
to the tube and a little water poured in through funnel and tubing. If the 
passage is clear, the prepared feeding may be given. The tube is then 
cleared by passing some plain water through, the spigot reinserted and the 
tube fastened down and covered. 

When the tube is not left in the wound, the lining of the organ-— in the rase of 
gastrostomy, the stomach wall — is brought up to and fastened to the skin 
of the anterior abdominal wall. A catheter must therefore be provided, and 
it is passed through this opening into the stomach and the feeding given 
by means of catlMter, tubmg and funnel. 



1 96 ARTIFICIAL FEEDING 

In this case the wound requires to be treated as an ordinary surgical 
dressing, and aseptic precautions should as far as possible be taken. 

Any oozing of the contents of the organ on to the surfece of the skin will 
cause soreness around the opening. To prevent this, it may be necessary to 
use an ointment dressing, Ae base of which should be liquid paraflSn or 
vaseline, as lanoline or lard would be affected by the digestive juices, 

THE ADMINISTRATION OF FLUID AND BLOOD 
TRANSFUSION 

The administration of fluid by a variety of channels is very important in 
the treatment of dehydration. By dehydration is meant the deprivation of 
the tissues of water, which occurs whenever large quantities of fluid are 
lost to the body by vomiting, diarrhoea or bleeding; and also whenever 
fluids are not circulating in the body as occurs in conditions of toxaemia 
and collapse. 

The symptoms of this condition include a rapid, thready, running, low ten- 
sion pulse; marked thirst, furring of the tongue and dryness of the mouth; 
the face is pinched and drawn and the eyes, deeply sunken in the sockets, 
appear dull and listless. The abdomen is retracted, and in severe cases the 
skin has the appearance of being shrivelled, as is a leaf when the sap is 
down. 

Babies and infants very rapidly become dehydrated, and when this hap- 
pens the temperature rises rapidly, as the heat regulating mechanism is 
easily disturbed in infants. 

The channel by which fluid may be administered is primarily the mouth but, 
if for any reason this is contraindicated, fluid may be given per rectum, by 
subcutaneous or intramuscular injection — though the latter method is 
comparatively rare — and by intravenous and intraperitoneai infusion. 

The fluids employed include plain w'ater, saline, gum saline, glucose 
5 per cent, or 10 per cent,, w^ater containing sodium bicarbonate i drachm 
to the pint, a 25 per cent. haemoglobin-Ringer solution, and transfusion 
of fresh blood, stored blood of different age^, blood plasma and blood 
serum (see p. 200). The amount given depends on certain factors: {a) 
whether any fluid is capable of being taken by mouth; (b) the need of the 
patient as demonstrated by his present condition (sec symptoms of dehy- 
dration, above); (c) the efficiency of the circulation which becomes de- 
vitalized and lowered when prostration and collapse are marked. In such 
serious cases, apart from the use of the intravenous method, only small 
quantities of fluid can be given at first. The administration may be made 
at frequent intervals, more considerable intervals, or continuously. The 
latter is resorted to when the means chosen is eitiier the rectum or the 
subcutaneous or intravenous route. In the latter case, as much as 6 to 10 
pints may be administered during 24 hours. 

Proctoclysis — or the administration of fluids per rectum. The 
apparatus required is a rubber catheter, attached to a tubing and funnel 
when small quantities arc administered at intervals (see illustration, fig, 50, 
p. 167). For continuous administration some form of vacuum flask is sup- 
plied, rubber tubing and catheter, into which a drip connexion, cither 
Ryall^s or Laurie’s, is inserted (sec fig, 84, p. 199). Above the connexion is 
placed a rubber tubing clamp in order to regulate the floWi and this regu* 



THE ADMINISTRATION OF FLUID 1 97 

lation is then inspected by means of the drip connexion, the average rate 
of flow being fi’om 40 to ^ drops per minute. 

Before a rectal administration can be made the lower bowel must be 
emptied, by an enema if necessary, and the expulsion of gas obtained by 
passing a flatus tube (see fig. 50, p. 167). Should the administration con- 
tinue over a number of days any interruption should be investigated, and 
similar treatment undertaken, unless it is found that a short pause is suffi- 
cient to overcome the difficulty. 

Hypodermoclysis — or subcutaneous injection. By means of this 
method fluid is absorbed principally by the lymphatics. All the apparatus 
used must be sterile and the skin into which the needles are to be inserted 
should be cleansed. The injection is made into some part where the tissue 
is loose such as the abdomen, axillae or thighs. The apparatus consists of 
one or two special needles attached to rubber tubing. If two needles are 
used, a Y-shaped connexion is employed, and the upper end of that is 
attached to a single piece of tubing and a funnel when only small quanti- 
ties are to be given; or to an irrigation can or vacuum flask if the adminis- 
tration is to be continuous, necessitating the preparation of larger quanti- 
ties (see fig. 61, p. 175). 

A similar drip connexion and tubing clips as before mentioned are used. 
The skin is purified, the saline is allowed to run through the apparatus to 
expel air, the tubing is clamped, the needles inserted as in the administra- 
tion of a hypodermic injection and the flow regulated. Some means should 
be taken to prevent the needles from either slipping out or being pulled 
out by any tension on the tubing. As a rule a small piece of elastoplast 
placed across the blunt end of the needle is sufficient support. 

During the administration, the nurse stands by the bedside and keeps 
the apparatus in working order, watching carefully for any tension of the 
skin under which the fluid is running. This must be avoided, and the rate 
should be so managed that the fluid is actually absorbed as rapidly as it 
flows in — otherwise, if it runs in too quickly, the resultant pressure may 
cause a sloughing of the tissues. The formation of an abscess is another, 
rather more remote, danger, but as this is solely due to bad surgical tech- 
nique it should be negligible, and hardly calls for mention here. 

'fhe amount that can be administered depends entirely on the absorp- 
tive powers of the tissues and no dogmatic statements can be made with 
regard to this. Occasionally when a subcutaneous infusion is to be made 
to infants, very small quantities only may be permissible, and in this case 
it may be administered by means of a lo-c.c. or 20-c.c. syinnge. 

INTRAVENOUS INFUSION AND BLOOD TRANSFUSION 

Venesection may be performed whenever large quantities of fluid, either 
saline or 5 per cent, glucose, arc to be administered or blood transfusion is 
to be made. The instruments required are shown in fig. 62, p. 176. Alter- 
natively a needle may be employed. 

Estimation of the haemoglobin content of the blood made at the outset 
and again at intervals during the transfusion in cases who arc bleeding acts 
as a guide to the rate of administration needed to compensate for loss of 
blood. Contimous blood drip transfusion has proved of considerable value in 
haematemesis, in marked anaemia and in post-operative bleeding. It can 



igS AKTIFICIAL rEEDINO 

be given before, during and after operation and in this way reduces the 
risk in operating on patients who are seriously ill, dehydrated and anae- 
mic. A vein in the forearm is opened and the catmula inserted. In Dr. 
Marriott’s method a reservoir which contains the blood is suspended about 
3 feet above the level of the bed and fitted with a nickel gauze filter to 
strain clots. The blood is delivered to the patient from an opening at the 
bottom of the reservoir, the rate of flow being observed by a Laurie drip 
tube and controlled by a screw clip. The blood in the reservoir is kept 
mixed by allowing a gentle stream of oxygen to flow into it; this is filtered 
by the insertion of three cotton wool filters at intervals in the tubing pass- 
ing firom cylinder to reservoir. The reservoir is also fitted with an outlet for 
oxygen. Very gentle bubbling is necessary and the fact that the mixing is 
adequate can be seen by the layer of from 2 to 3 inches of froth on the 
surface of the blood. In addition to mixing the blood so that the red cells 
do not collect at the bottom of the reservoir, oxygen also oxygenates it. 

EMERGENCY TRANSFUSION APPARATUS FOR 
INTRAVENOUS INFUSION 

The Emergency Transfusion bottle contains 180 c.c.’s of anti-coagulant 
and is fitted with a screw cap. 

For taking blood the metal cap, having been removed, is stood on a sterile 
towel and a rubber bung containing two holes is inserted; two short glass 
tubes pass through this bung. One is connected by a piece of rubber 
tubing, containing a window, to the needle for withdrawing blood, and 
the other to a piece of rubber tubing which contains two cotton wool fil- 
ters. The free end of this tubing is attached by means of a glass connexion 
to a Higginson’s syringe ^see fig. 63, p. 177) which the patient holds in his 
hand and squeezes gently, thus maintaining the circulation in his arm and 
the flow of blood from the vein to the bottle. Three hundred and sixty 
cubic centimetres of blood arc withdrawn, the rubber bung is removed, 
the metal cap replaced and the bottle labelled. The blood is stored at 4° C. 
and can be kept at least for a fortnight and sometimes for a month depend- 
ing on the rate of haemolysis. 

For giving blood the bottle is taken from the cold chamber, inverted once 
or twice and warmed by standing in a bowl of water at blood heat for at 
least half an hour. The metal cap is removed and a rubber bung contain- 
ing one long glass tube plugged with cotton wool to act as an air-inlet and 
filter and one short glass tu^ guarded by a ‘gas mantle filter’ is inserted. 
To the short tube a length of rubber tubing is attached containing a 
Laurie drip bulb and screw clamp for regulating the flow of blood when 
the bottle is inverted and hung over the patient’s bed. The lower end of 
the tubing is attached to a needle by means of a record fitting adaptor; 
alternatively Kaufrnaim’s syringe (see fig. 65, p. 177) or canmUa may be 
used. (The same method is also convenient for the administration of plas- 
ma, glucose, saline, &c.) 

In the nursing care of a patient who is having a blood drip trandlision it 
is important to see that the rate of flow order^ — usually 30 to 60 drops a 
minute — is maintained. If the flow ceases clotting will take plau:e in the 
cannula and provide an obstruction to subsequent flow and necessitate 
changing the vein. If the patient complains of pain in the arm this should 
be reported as it may be due to phlebitis. In the administration of con- 



EMERGENCY TRANSFUSION APPARATUS 1 99 

tinuouB infusion of blood it has been found advisable to change the vein 
afkor 84 hours, as there is a tendency to phlebitis when a vein has been used 
for some time. 



Fio. 84. Administration of Blood Transfusion. 

(A) Reservoir with perforated rubber bung through which two glass tubes past — ^the 
tube conveying the oxygen ends in an inverted thistle fuimel — the oxygen bubbles 
through the blood and escapes by means of the second shorter tube. At the bottom of 
the reservoir is a gauze filter. (B), (C) and (D) three cotton wool Alters inserted in the 
tubing conveying oxygen to the reservoir. (E) rubber tubing clip. (F) Laurie’s drip bulb. 
(G) graduated glass connexion — from the lower end of wUch pressure tubing conveys 
the blood to the cannula inserted in a vein of the forearm. 

COMPLICATIONS IN INTRAVENOUS INFUSION 

A rigor is the complication most often heard of. It is now considered to be 
due to dead organisms in the solution used, due to its being prepared with 
imperfectly distilled water, and it is a very rare occurrence indeed when 
this j»int is attended to. 

Pain in the chest accompanied by some distress of breathing or general restless* 
ness may occur. This is thought to be due to too rapid administration, 


200 ARTIFICIAL FEEDING 

resulting in dilatation of the right side of the heart Decreasing the rate of 
infusion will usually give relief; if it does not do so^ the treatment is usually 
stopped. 

In blood transfusion sorne degree of haemolysis may result from rapid break- 
down of the red blood cells. This will be followed by jaundice, symptoms 
of which may be accompanied by a rise in temperature and rigors. Rapid 
haemolysis might prove fatal, but as the grouping of blood (sec note below) 
is undertaken in order to avoid such a catas^ophe, it is unlikely to occur. 

Sepsis will only occur if there has been faulty surgical technique. 

Thrombosis and phlebitis may occur locally. 


GROUPING OF BLOOD 

In order to prevent a blood transfusion from being complicated by hae- 
molysis of the red blood cells due to non-compatibility of the bloods of 
donor and recipient, tlie blood of humans has been classified into four 
principal groups. The International use of the nomenclature of Von Dun- 
gern and Hirszfeld, O, A, B, and AB, which is based on the agglutinogen- 
content of the blood, has superseded the use of the Moss system of grouping. 


New Terminology. 


Old Terminology. Number of people 
(Moss system) in each group. 


AB (Universal Recipient) ... I Under 5% 

A II About 40% 

B ...... . Ill About 10% 

O (Universal Donor) . . . . j JV About 40% 


To facilitate recognition of the different groups when these arc stored, a 
definite colour-scheme is used in labelling the blood. 


Group AB White 
,, B Pink 


Group A Yellow 
„ O Blue 


PLASMA AND SERUM 

Plasma and serum are supyerseding blood for transfusion purposes as 
these substances are more easily stored. Agglutinin-free plasma is tne ideal 
one. It is made by mixing fresh blood from the various groups, particularly 
A and B, and can be used for every individual of whatever olo^ ^roup he 
may be. Dried Plasma is also prepared which can be rcdissolvcd m sterile 
water and made up to the ordinary concentration of blood proteins, or a 
higher concentration can be prepared. By this means a higher percentage 
of blood proteins can be administered in a given quantity of fluid. 

Serum is also employed, and it possesses certain advantages. It is easily 
prepared and is more stable than plasma and does not clot. It is useful 
when prolonged storage is necessary, it can be transported long distances 
and into warm climates. 


MERITS OF FLUIDS AVAILABLE 

Transfusion is performed with two main objects {a) restoring the oj^gen^ 
carrying capacity of the bloody as in the treatment of the anaemias when £^sh 
blo^ is needed because the red cells arc essentiali and {b) in order to w- 



MERITS OP FLUIDS AVAILABLE 201 

tare the blood volume and blood pressure when any innocuous fluid which can be 
retained in the circulation may be employed. For this purpose the blood 
derivatives arc best — stored blood, prepared plaisma and scrum as these 
contain blood proteins. 

Other available fluids include gum saline, isotonic saline (normal saline) 
and isotonic glucose. Of these gum saline is the most efficacious, but all 
these fluids are evanescent, and the transfused fluid rapidly leaves the cir- 
culation and is excreted by the kidneys. 

RH OR RHESUS FACTOR IN BLOOD 

Blood grouping as described above has been made in order to avoid 
putting non-compatible bloods, which would cause haemolysis of the red 
cells, together in giving blood transfusion. Another, more recently investi- 
gated factor which causes red blood cell destruction, particularly in the 
foetus and newly bom, has been described as the rhesus factor because it is 
found in the Rh cells of rhesus monkeys. About 85 per cent, of humans are 
rhesus-positive the remaining 15 per cent, being rhesus-negative. 

Haemolytic disease in infants has been traced to the fact that the mother 
being Rh-negative, the father Rh-positive, the infant may be Rh-positive 
but, owing to the mixture in the foetal blood the mother’s blood develops 
antibodies to the rhesus factor which will destroy the red blood cells of the 
foetus or the newly born. This is not the only cause of haemolytic disease 
in infants, but it is a cause which, in the past has, in some cases, proved 
fatal. With the knowledge that is now available it is pK)ssible to transfuse 
blood into the infant containing the Rh factor and in this way the infant 
is kept alive until all the antib^ies to the Rh factor present in his blood 
at buth have been eliminated and the new red blood cells being formed 
are no longer destroyed. 



Chapter 12 

Aspiration and Drainage of Body Cavities 

Aspiration of the pleural cavity and the pericardial sac — Tapping the abdomen — 
Drainage of the subcutaneous tissue — Lumbar puncture and cisternal puncture. 

ASPIRATION AND TAPPING 

T he nurse will be exp)ected to prepare both j>atient and apparatus for 
the performance of different forms of aspiration and paracentesis, 
or tapping, in order to remove fluid from the various cavities of the 
body. The operation of paracentesis consists of passing a hollow needle into 
the cavity from which the fluid is to be taken; the fluid, being under pres- 
sure in the cavity, will then run out as when a beer barrel is tapped. The 
term "aspiration* is used to describe the evacuation of a cavity when the 
fluid will not run out in the same way, and where some form of suction 
has to be employed in order to procure its evacuation, as in the case of the 
pleural cavity. 

The chief reasons why any form of evacuation of a cavity is under taken 
are: (i) for examination of the fluid contained in it; (2) for the relief of 
pressure caused by the fluid; and (3) to remove fluid in order to replace it 
by some other sul^tance, such as saline, or serum. 

With regard to the preparation of the apparatua and of the 
patient a few general rules may be laid down. In preparing appara- 
tus strict asepsis is essential in order to prevent infection. The inspection of the 
apparatus is very necessary in order to see that it is in good working orfer; 
otherwise time will be lost and the patient will be inconvenienced by the 
delay. Great care should be taken to see that any sharp instruments are really 
sharp and that the stilettes fit the needles for which they are intended, and that 
in the same way trocars fit the cannulae. In the latter case it is very impor- 
tant that the trocar should only extend to the edge of the cannula. When a 
bevelled trocar is used, as in the case of Barker’s needle for lumbar punc- 
ture, it must exactly fit the bevelled edge of the needle. 

With regard to preparation of the patient^ the nature of the exploration 
should if possible be explained to him. He should be told that as little dis- 
comfort as possible will be caused, and that a local anaesthetic will be used 
so that he docs not feel the injection or puncture. The skin should be pre- 
pared as for a surgical operation. The patient must be made exceedingly 
comfortable in the position he is to adopt, as he may be required to main- 
tain it for several minutes. If he moves, it may interfere with the operation, 
particularly in exploration of the pleura. 

In addition, the nurse ought to know the effects that are expected from 
the investigation made, and she should be familiar beforehand with any 
untoward symptoms which may possibly arise during the performance of 
it. She should watch both the patient and the physician or surgeon, and be 
able to anticipate the wants of both without their having to give expression 
to them. She should supply the necessary specimen bottles with bungs or 
corks to fit, and have the appropriate pathological labels ready at hand. 


zoz 



A8MRATI6N AND TAPWNO 20^ 

She should Have inquired beforehand tvhcthcr the specimen is to be sent 
at once, as may be required in cases where it b essential that it should be 
deliver^ warm to the laboratory, and in this case she should have ready 
some fluid at body temperature in which the test tube or other receptacle 
can be placed. 


ASPIRATION OF THE PLEURAL CAVITY, OR 
THORACENTESIS 

This operation is performed for the rdhef of symptoms in cases of pleural 
effusion, and also in some instances in order to collect a specimen of flmd 
for examination. The articles required include: Potain’s aspirator (see figs. 
66 and 67, p. 178), or an aspirating syiinge may be employed. 

Hypodermic syringe and needle, charged if necessary with a local anaesthe- 
tic. Ethyl chloride may be necessary. 

Articles for cleansing the skin, including alcohol or some antiseptic, together 
with swabs for its application, and a receiver for soiled swabs. 

Sterile test tubes for the reception of specimens of the fluid and some form 
of lx)wl or laigfc receiver for the collection of further fluid should be pro- 
vided. 

Sterile towels and dressings — gauze and collodion, and cither adhesive 
strapping, elastoplast, bandage or binder for securing the dressing in posi- 
tion, may be required. 

A sputum cup should be at hand in case the patient wbhes to use it, and a 
dose of stimulant should be provided such as brandy and water, in case he 
feels weak and faint. 

The aspirator should be tested as follows — Insert the rubber 
bung with its connecting tubes into the glass botde. Attach the pump to 
the proximal side and place the tubing on the dbtal side in a bowl of 
sterile water. Then adjust the taps, having the proximal tap opened and 
the dbtal one closed. The tap b open when it lies horizontally or in a line 
with the tubing, and closed when it lies at right angles, across the tubing. 
Having made certain that the rubber bung fits well into the neck of the 
liottle, to prevent the entrance of air, and seeing that all other connexions 
arc similarly secure, the nurse then pumps rapidly and rhythmic.ally for 
two or three minutes. 

To test the vacuum, she then turns off the tap on the proximal end, and 
turns on the distal tap, when, if a vacuum has been formed, water will 
rush into the flask from the porringer of water in which the distal tube is 
lying. 

Preparation of the patient. Having told the patient the nature of the 
operation, and allowed him, if it seems at all reasonable, to sec the appara- 
tus that b to be used, including the small size of the needle witli which the 
puncture b to be made, and the local anaesthetic which b to be used to 
prevent his feeling even the tiny prick of thb, he b placed in position. As a 
rule he b arrang^ cither leaning forwards over a bedtable or pillow, on 
his knees, with ms arm on the side to be treated carried well forward across 
his body in front of hb chest in order to separate the intercostal spaces and 
keep the scapula well up out of the way. Or he may be arranged lying on 
the unaffected side with a firm pillow under hb chest, so that he lies wth 
his trunk flexed laterally over tne pillow. The arm on the affected side b 



204 DRAINAGE OF BODY CAVITIES 

carried up over his head and the patient may gra^ the rail at the bedhead, 
or clutch the mattress, or have his hand held in this p>osition by a nurse. 

The skin is then prepared, the bedclothes rearranged and towels are 
placed around the area of injection. The physician applies the local 
anaesthetic and passes the needle into the chest. The ne^e is then at- 
tached to the tubing on the distal side of the aspirator bottle in which a 
partial vacuum has been created, and if the needle has tapped the fluid in 
the cavity this will flow into the bottle. 

The nurse assures the patient that all is going well, and tells him that if 
he wishes to cough or move he must first inform her. She watches his colour 
and pulse very carefully and reports any change. 

When the operation is completed the needle is withdrawn and the punc- 
ture scaled by collodion or covered by the dressing provided. The appara- 
tus is removed to a convenient place, the patient is made comfortable in 
his usual position in bed, given a stimulant if necessary — ^if not, he is given 
a drink, and the nurse then clears the apparatus away. She has already 
inquired what is to be done with the fluid, and collected a specimen if 
necessary; the remainder of the fluid should be measured and inspected 
for colour, odour and any abnormal appearance, and then thrown away. 

She may now proceed to clean the apparatus. Fluid from the body prob- 
ably contains albumin, which is a coagulable substance. To cleanse the 
tubing and apparatus it may be reassembled as described when testing it, 
and clean, cold water drawn through it several times; when quite clear of 
all albuminous fluid an antiseptic may be drawn through — preferably one 
of a non-soapy nature such as i /20 carbolic. The bottle, and the stopper 
with its connecting tubing, may then either be sterilized by boiling or dis- 
infected by soaking in carbolic 1/20 for one hour. At the end of mis time 
the apparatus should be dried. Spirit may be drawn through it in the same 
way as the water, or spirit may be syringed through the tubing. The tubing 
and connexions should then be well shaken to free them of excess spirit, 
and hung up to dry before being replaced in the box in which the appara- 
tus may be kept. The glass bottle should be thoroughly polished with a dry 
duster. The aspirating needle and hypodermic syringe and needle used 
may be cleaned as described on p. 619. 

ASPIRATION OF THE PERICARDIAL SAC 

The same apparatus as previously described may be employed, but, as 
the amount of fluid withdrawn from the pericardial cavity is small com- 
pared with that from the thoracic cavity, a 10 or 20 c.c. syrinx and needle 
are usually found to be adequate. The front of the patient's chest is ex- 
posed, and he may either lie on his back, or be propped up with pillows. 
As considerable shock may attend this operation the nurse should watch 
the patient very carefully for changes of colour and irregularities of pulse. 

TAPPING THE ABDOMEN. OR PARACENTESIS 
ABDOMINIS 

Tapping the peritoneal cavity for the removal of fluid is usually under- 
taken for me relief of troublesome symptoms produced by ascites. It is im- 
portant for the nurse to realize that the removal of a large quantity oi fluid 
will decrease the intra-abdominal pressure, and may give rise to con- 
siderable shock to the patient. 



TAPPING THE ABDOMEN 205 

The articles required (see figs. 68 and 69, p. 179) include a scalpel for 
making the initial incision in cases in which a large trocar and cannula is 
employed. 

A trocar and cannula of the size required, which may be an ordinary lai^ 
abdominal instrument, or Southey’s tubes, may employed. Rubber 
tubing should be supplied of a suitable size to fit the trocar and cannula, 
and it should be long enough to convey the fluid from the abdomen to the 
receptacle provided for it. When a large quantity of fluid is expected, as is 
usually the case, a pail is placed at the bedside lor its reception. 

A sterile specimen bottle may be required if a specimen of the fluid is 
wanted. Sterile towels and sterile dressings will be needed and an abdominal 
binder cither of the usual many-tailed type, or of a special type designed 
for the application of pressure daring the escape of the fluid from the 
abdomin^ cavity, in order to overcome the rapidly decreasing intra- 
abdominal pressure, and so combat the ill effects which might result. 

A stimulant should always be at hand and water or some other drink for 
the patient who may need it during the operation. 

Instruments provided should include dissecting forceps, scissors and 
needles; also sutures for suturing the edges of the small incision, together 
with suitable dressings, binder and safety pins. 

Preparation of the patient. The patient will be propped up in a 
sitting posture, as required by the degree of ascites present. As the punc- 
ture is made in the mid line it is essential for the bladder to be empty, and 
when collecting the apparatus the nurse must provide a suitable bedpan 
or urinal, and also have ready at hand the articles for catheterizing the 
patient. 

The binder should be placed ready behind the patient in case it is neces- 
sary to use it as described above during the escape of fluid. 

The skin is prepared, anaesthetized, the incision made and the trocar 
inserted. The rubber tubing provided is attached to the distal end of this, 
and the end of the tubing is placed in a receiver into which the fluid is to 
pass. The tubing should be long enough to reach to the bottom of the 
article provided for the reception of the fluid. 

It is very important to watch the patient’s pulse carefully, and the nurse 
should stand at the patient’s bedside with her hand on the pulse, and if it 
loses volume and tone she should at once give the patient a dose of the 
stimulant which lies ready at hand, and at the same time .adjust the binder 
in order to help maintain intra-abdominal pressure. 

At the termination of the treatment the carmula is removed. If an initial 
incision was made, a local anaesthetic is used and the wound sutured; a 
suitable sterile dressing is applied, the binder firmly adjusted and secured 
in position by safety pins. The patient should be made comfortable in his 
I )cd, but should be moved as little as possible, since the movement of a 
patient who has just undergone an operation is liable to induce shock The 
patient must be very carefully watched for some hours, and the binder, 
which must not be allowed to get slack, should be readjusted from time to 
time. 

Drainage of the subcutaneous tissue may be carried out by means 
of acupuncture — ^when minute punctures are made in the skin by means of a 
sharp stcr^ scalpel, the fluid which runs out being collated in large pads 
ot sterile gauze and wool; or Southey's tubes may be employed. These tiny 



2o6 drainao® of »ody csAvrriEs 

tubes arc shown in illustration, fig. 69, p, 1 79, each one consisting of a silver 
cannula; in the illustration under figure A one silver cannula is depicted 
with the trocar inserted ready for use, and a second is shown with tubing 
attached after the trocar has been withdrawn. 

A number of these cannulae may be employed; they are introduced into 
the oedematous tissue of the legs and thighs and die fluid drains either into 
bowls or receivers placed in the bed, or into a large pad of gauze and wool, 
which is changed as soon as it is saturated. It may be necessary to use a 
small strip of clastoplast to prevent the cannula from slipping out if the 
patient is restless. 

The limbs that are being drained should be kept warm by beit^ 
wrapped in cotton wool and the weight of the b^clothes should be 
removed from them by means of a low bcdcradle. 

LUMBAR PUNCTURE 

Lumbar puncture is performed to tap the fluid in the subarachnoid space 
or, as it is sometimes called, the iheca. It may be performed for several 
reasons : (a) to remove cerebrospinal fluid for examination purposes, (b) to 
remove fluid preliminary to the introduction of drugs, saline or serum, &c., 

(c) to ascertain the pressure of the cerebrospinal fluid, in which case a glass 
manometer is fitted to the apparatus used (Greenfield’s apparatus), and 

(d) to remove fluid for tlie relief of intracranial pressure in a variety of 
cases including meningitis and conditions of oedema of the brain. 

The apparatus generally used (see fig. 70, p. 180) is a Barker’s 
lumbar puncture needle. It is a long needle with a finely bevelled 
point, and is fitted with a stilettc, which is also bevelled, so that when 
placed in the correct position it completely fiUs the point of the needle, and 
the two together present a smooth bevelled cutting edge. Barker’s needle 
is so adapted that the stilette has a little metal projection on the hilt which 
fits into a corresponding groove on the hilt 01 the cannula so that when 
these two are adapted the stilette is in the correct position. This special 
needle is made so that it will fit on to a record syringe, which should also 
be ready sterilized in case it may be required for withdrawing fluid should 
the pressure in the theca be exceedingly low. 

One or two sterile test tubes should be in readiness for the collection of 
specimens of the fluid. In handling these test tubes two points arc of im- 
portance — the fluid collected may be infectious, as in cases of cerebrospinal 
meningitis, and it is therefore important that the outside of the tube should 
not be contaminated. If it becomes contaminated the surface should be 
washed with alcohol, and the nurse who handles it should wash her hands. 
The second point is that in some cases the fluid should be conveyed warm 
to the laboratory where it is to be examined. 

A local anaesthetic should be supplied, cither novocain 2 per cent, and a 
hypodermic syringe, or an etliyl chloride spray. 

Antiseptic lotions and swabs will be required for clcasing the skin; any anti- 
septic may be employed, but iodine should be avoided if an ethyl chloride 
spray is to be used, as the effect of freezing skin punted with iodine is to 
render it tough. A collodion dressing is usuaJuy iq>pUed to the puncture. 

A drifA should be supplied in case the patient feels laint or weak as the 
remit of the treatment, and in some cases a stimulant may be used. 



LUMBAR PUNCTURE 


207 

Preparation of the patient. This operation is usually performed with 
the patient lying in the left lateral position with his thighs flexed on the 
abdomen, the knees flexed on the thighs and the head and shoulders 
drawn forward on to the front of the chest, so that the spine is as thor- 
oughly flexed as possible and, therefore, the vertebral spines will be com- 
paratively well separated, thus facilitating the passage of the needle be- 
tween them. 

The skin is cleansed over the area to be treated. As a rule the interval 
between the second and third or third and fourth lumbar vertebrae is 
punctured. If the nurse is in doubt as to the position of these bones, she 
can determine the level of the second or third lumbar vertebra by drawing 
her finger in a straight line from tlie top of the crest of the ilium to the 
middle of the patient’s back. She should hold the patient in the curled up, 
flexed position whilst the puncture is made. 

Another position in which this operation is sometimes carried out is to 
have the patient seated on a stool and leaning forward on some support 
placed in front of him, or, if he can manage it, with his hands clasped 
round his knees. The nurse stands in front of him and places her hands 
on the posterior aspect of his shoulders and keeps his trunk flexed, allowing 
him to rest his head against her side. 

After lumbar puncture has been performed, the foot of the patient’s bed 
should be elevated for some hours. If scrum or any other fluid has been 
injected, this will facilitate its circulation more rapidly round the brain 
and cord. If' fluid has been removed, it prevents the headache which 
might result from suddenly draining the fluid away from the venu icles of 
the brain. 

Cisternal puncture is performed when it is desirable to obtain cere- 
brospinal fluid, or to inject serum or some other fluid, when this cannot 
be performed by lumbar puncture. A needle, similar to Barker s needle 
but shorter and finer, is passed beneath the skull, between it and the first 
cervical vertebra, into the cistema magna^ which is the portion of the sub- 
arachnoid space lying between the cerebellum and the medulla oblongata. 

'Fhc back of the head is shaved as far up as the external occipital pro- 
tuberance, the skin cleansed and a local anaesthetic applied; when the 
needle is inserted the head should be held forwau-d on to the chest. 

Cisternal puncture may be performed in conjunction with lumbar punc- 
ture in the investigation of spinal canal obstruction. Differences in Uie 
composition and in the pressure of the spinal fluid above and below tlic 
point of obstruction may be a guide in diagnosis (sec also lipiodol injection, 
p. 210). 



Chipter 13 

Some Investigations and Tests 

X^ray examinaiion of the alimentary tract — The use of Itpiodol in X-ray examina- 
tion — Examination of the function of the gallbladdn — Examination of the function 
of the kidneys — Examination of the urinary bladder — Examination of the sigmoid 
colon — Gastric analysis — Glucose tolerance test — {See also pp. 486^ 44g^ 
47 1 y 472y 53<S, and 5^5 for the tuberculin testSy the Widal testy tests used in the 
diagnosis of some of the infectious diseasesy the Wassermann reaction and tests 

of pregnancy) 

I n order that a nurse may the more intelligently understand and appre- 
ciate the treatment which is being carried out, she ought to have some 
idea of the nature of the commoner investigations and tests which she 
will, from time to time, see undertaken and for which she may have to 
prepare her patient as well as, in some cases, the apparatus. 

DIAGNOSTIC X-RAY EXAMINATION 

General notes on considerations to be made on taking any patient to the X-ray room 
for examination. The patient should be suitably clothed; all articles used 
should be such as can be easily removed and rearranged without exposure 
of the patient. Some easily manipulated garment, such as a shawl or small 
blanket or shoulder wrap, should be at hand to cover the patient’s shoul- 
ders if he has to wait for any reason — such as the recharging of a plate car- 
rier or whilst a film is developed. 

The clothing should be quite free from all articles known to be imper- 
vious to X rays, such as metal buttons, and such things as keys or a watch 
should be taken out of the patient’s pockets. Silk garments should not be 
worn. If the head is to be X-rayed all hairpins, slides, combs and ribbon 
should be removed. Dentures should be taken out, at the last moment, and 
kept safely. If splints are used, wooden ones are preferable, metal should 
not be us^; bandages should not contain safety pins and strapping ought 
not to be employed. 

The patient should be informed, as clearly as possible, what is to be done 
and the help expected from him. He will have to lie very still, and CTcat 
pains should be taken to see that he is comfortably placed on the table or 
other piece of apparatus on which he is to lie, or rest. 

X rays were first employed in the diagnosis of conditions in tissues which, 
because of their calcium content, arc opaque to X rays, such as the bones, 
and in cases of urinary stone. Later, X rays began to be employed in the 
examination and diagnosis of conditions of the alimentary tract. At first, 
bismuth was administered for examination of the upper part of the tract, 
and barium for enemata. At the present day, the use of barium has super- 
seded that of bismuth almost entirely; a barium meal consists of about 4 
ounces of barium in a pint of Horlick’s malted milk, or cocoa. In a barium 
enemay i to 2 pounds of barium arc mixed in 4 pints of mucilage of traga- 
canth. 

aoS 



DIAONOSTIO X'RAY EXAMINATION 20^ 

Examination of the alimentary tract is undertaken for a number of 
reasons and to diagnose a great number of conditions and diseases, in- 
cluding: 

(a) stricture of the oesophagus; in this condition the barium will be observed 
above the obstruction when complete; 

(b) cardiospasm. The barium will lie curled up at the cardiac orifice, 
owing to closure of the latter by spasm. 

(c) examination of the stomach. Normally the contour of the organ will 
be regular in oudine and the waves of peristalsis will be seen passing along 
it at regular intervals. In the event of disease or abnormality, the stomach 
may be seen to be dilated; in carcinoma there is often irregularity of filling, 
with deformity of the contour of the stomach; in peptic ulcer, the crater of 
the ulcer can be seen, accompanied by spasm of the corresponding segment 
of the organ. The rate of emptying of the stomach is usually investigated; 
it may empty quickly when the organ is hypertonic; alternatively, a residue 
will be seen, after 4 hours, in cases of pyloric obstruction. 

{d) visceroptosis; the stomach or any part of the intestine — particularly the 
caecum — may be seen to be displaced. 

(e) examination of the large intestine, the appendix should be seen to fill 
and empty normally; any narrowing of the lumen of the gut would be 
noticed; arrest of the passage of the barium would be caus^ by obstruc- 
tion, spasm or stricture; in diverticulitis small pouches would be seen. 

Preparation of a patient for X-ray investigation of the alimentary tract. A light 
diet should be given for a few days before the examination is to be made; 
any medicine containing bismuth must be omitted during this period. For 
examination of the stomach and small intestine the patient should be fast- 
ing from the previous evening; for examination of the colon a light break- 
fast is allowed. 

In order to empty the alimentary tract, an aperient such as castor oil, from 
half to one ounce, should be given 48 hours before the time of examina- 
tion, and in some cases this is repeated again, 24 hours before. It should be 
followed by a simple enema, 6 hours beforehand, if necessary. In many 
cases a dose of any aperient the patient is familiar with may be substituted 
for castor oil; but aperients that arc known to cause flatulent distension — 
such as magnesimn sulphate — should be avoided. Some flatulence is in- 
variably present after the use of any aperient, and to overcome this many 
physicians order a dose of pituitrin, or arrange to have a flatus tube passed 
a short time before the examination is to take place. When the stomach is 
the site of examination an opiate mixture may be ordered 4-hourly, or 
6-hourly, for 12 hours before the examination. 

X-ray examination of the stomach is usually carried out early in the morning. The 
prepared barium meal is given in the X-ray room, and the first examina- 
tion made about g o’clock (see fig. 71, p. i8i), subsequent ones being 
carried out at intervals of three hours, in order to note Ae rate at which 
the barium passes along the tract. It is very important that a patient 
undergoing this examination should be kept warm, and permitted to rest 
comfortably, either in his own bed, or in a rest room adjoining the X-ray 
depM^ent. It is essential that everyone, including the patient himself, 
should clearly understand that, until Ac final examination has been made, 
he may not have anything by moudi — ^neither food, drink nor medicine. 
He will be feeling very wt^ and tired after his long and difficult fs^t and, 



210 BOMB IN VESTIOATIONS AMD TESTS 

as soon as the last examination has been made, he should be given a light 
meal. 

When the colon is the site of examination, a barium enema will be given to 
the patient in the X-ray room (sec fig. 7a, p. 182). It is import^t to 
remember that mackintoshes should not be used as this material is im- 
pervious to X rays. 

Lipiodol examination. Lipiodol is a fikty substance which contains a 
certain amount of iodine and is opaque to X rays. It is used for several 
examinations : 

{a) for inspection of the character of the bronchial tree, in cases of bronchiectasis. 
About 4 c.c. of the substance is passed into the trachea, by introduction 
through the crico-thyroid membrane. The patient lies on the side which is 
to be examined and the lipiodol trickles down into the branches of the 
bronchi, which can then be seen on X-ray examination (see fig. 73, p. 183). 

{b) in the diagnosis of the position of tumours of the spinal cord. It is injected 
into the subarachnoid space, usually at the base of the skull, and will trickle 
down and become arrested at the site of the tumour. 

(c) to determine the presence of stricture of the fallopian tubes, the prepar- 
ation of lipiodol being injected into the uterus, under pressure, in cases sus- 
pected of sterility and, if this is due to stricture of the tubes, the lipiodol 
will be seen held up, and rmable to pass the stricture, on subsequent X- 
ray examination (see fig. 74, p. 184). 

{d) injected into sinuses to facilitate investigation of their extent by X-ray 
examination. 

Encephalography and ventriculography. In both these investiga- 
dons radiograms are taken after the withdrawal of fluid from the ventricles 
of the brain and its replacement with air. The examinadon is undertaken 
as an aid to diagnosis of the presence of a tumour of the brain which would 
cause displacement of the fluid injected into the ventricles. 

Ventriculography is only undertaken as a last measure, as it requires a sur- 
gical operadon. Holes are drilled in both parietal bones and air is injected 
directly into the ventricles. 

In encephalography lumbar puncture is performed, and air injected into the 
theca rises and fills the ventricles. The patient is given morphia gr. i /4th 
and hyoscinc gr. i/i50th, or two-thirds of a grain of omnopon before die 
investigation is made. The ardcles required for the performance of cn- 
cephalc^;raphy are shown in fig. 75, p. 185. The padent sits on a stool, the 
lower part of his back is uncovered and a stcr^e towel is draped over 
his clothing; it is kept in position by means of two towel clips. Lumbar 
puncture is performed, and 5 c.c. of fluid is withdrawn. Then 5 c.c. of air 
is drawn through sterile cotton wool into an easily moving glass syringe 
and injected into the theca. 

The withdrawal of fluid and its replacement by air is repeated until from 
50 to 60 c.c. of fltxid has been withdrawn and the same quantity of air has 
been injected. During the treatment die patient’s head is slowly raised 
and lowered in order to get better diflusicm of air in the ventricular spaces. 
He is X-rayed in different positions as air being light will tend to nse, so 
that when for example he is placed on his right side air may be expected 
to show in the left ventricle. 

As the result df this investigation the patient will have very severe head- 
ache; he is taken back to the ward and put to bed and is generally given a 



mAG««OSTIC X^RAY EXAMINATION 21 1 

do*c of oiorpliia for the relief of pain. His hed should be elevated at the 
foot on block) 1 2 inches high in o^er to encourage the circulation of cere- 
brospinal fluid in the ventricles which have been drained. The headache 
usually subsides in 24 hours; in the meantime the patient should be en- 
couraged to take plenty of flt^ to drink. His pulse should be recorded and 
in some cases the physician will wish the blood fn-essure taken also. 

For diagwsiic txamination of the kidneys see p. 212; and of the gallbladder, 
see below. 


EXAMINATION OF THE FUNCTIONAL ACTIVITY OF THE 

GALLBLADDER 

The gallbladder normally empties its contents into the duodenum. In 
its function of storing bile, it also concentrates this substance and, when 
diseased or disordared, this function may be impaired. Direct examination 
of the gallbladder has been proved unsatisfactory and the examination 
describe below as cholecystography has entirely superseded this method. 

Examination of the character of the bile can be made by means of Lyon’s 
system of gallbladder drainage. 

Cholecystography. Graham’s test. Dr. Graham discovered that 
opaque salts were removed from the blood by the liver and concentrated 
in the gallbladder. This rendered it possible to investigate the outline of 
the gallbladder by X-ray examination. 

Preparation. The routine general preparation is carried out as described 
on p. 208. The very light evening meal given the day before should be 
entirely devoid of butter, milk and all other fats. The examination is to be 
made fasting, and the patient should not be given any medicine or per- 
mitted to see or smell food, for fear of stimulating the activity of the gall- 
bladder. 

A special dye (opacol) is used. It may either be taken by mouth or in- 
jected intravenously. If given by mouth 6 grammes, or even 8 grammes 
for a fat person, are given with citric acid and sugar at 6 p.m. the evening 
before the examination is to take place, and photographs are taken at 
nine and twelve the following day. When the dye is administered by the 
intravenous route, it is important that none of the dye should be permitted 
to escape into the tissues during the administration, as thb would result in 
ulceration and sloughing; moreover, the administration of the dye should 
be followed by passing a small quantity of sterile saline through the needle 
into the vein so that it is completely washed out before it is withdrawn. 

If the gallbladder is concentrating normally a shadow of the organ will 
be seen on X-ray examination (see fig. 77, p. 187). When gallstones are 
present there will be lack of uniformity of shadow, and if there is no 
shadow it indicates that the gallbladder is not concentrating and is there- 
fore not functioning normally. It Ls of interest for the nui-sc to know that 
a good outline should show in a normal gallbladder at the first examina- 
tion; at the second examination it should show a mere shadow, and at the 
third examination it should be empty. 

The first examination is made at 9 a.m. and the second at about 12 
ooon. If shadow is sdll visible at noon a third examination is made, but 
before this a meal rich in fat is given. A cup of cocoa, with bread and but- 
ter and egg, is frequently employed. This causes the g^bladder to empty. 



212 SOME INVESTIGATIONS AND TESTS 

Lyon’s gallbladder drainage. This is also described as non-surgical 
drainage of the gallbladder, and is carried out by the administration of a small 
dose of concentrated magnesium sulphate pour«l into the duodenum by 
means of a Ryle’s tube. 

Preparation. The patient is given a comparatively non-fatty supper the 
previous evening. Lean meat, brown bread and stewed prunes are fre- 
quently given. He is then told not to swallow his saliva when he wakens 
the next morning, but instead to rinse his mouth out with a mild antiseptic 
wash. 

Method. A Ryle’s tube is passed, and the resting juice drawn off the 
stomach, as in the preparation for a test meal (see p. 215). The patient is 
then turned on to his right side and the tube is passed a little farther, in 
the hope that it may enter and lie in the duodenum. Twenty c.c. of 25 
per cent, magnesium sulphate solution is introduced by means of a record 
syringe attached to the end of the tube, at the lips. Fifteen minutes later 
fluid is drawn off at short intervals by means of the record syringe until a 
bright yellow specimen is obtained. This is labelled ‘Specimen i ’. It is tested 
with litmus, and if found to be acid the tube is considered to be in the 
stomach. A funnel is then attached to the duodenal tube and sterile water 
poured down into the stomach; this may stimulate peristalsis and cause 
the end of the tube to be carried through the pylorus, into the duodenum. 

Specimens are collected at intervads until a dark coloured alkaline 
specimen is obtained, and this is labelled ‘Specimen 2’. When no more fluid 
can be obtained, 50 c.c. of the magnesium sulphate solution is poured in. 
This causes the gallbladder to act, and when a golden brown specimen is 
obtained it is put up in a glass labelled ‘Specimen 3’. 


EXAMINATION OF THE FUNCTIONAL ACTIVITY OF THE 

KIDNEYS 

The examination of the functional activity of the kidneys is an important 
part of the preparation of a patient for an operation on any part of the 
genito-urinary tract. This examination includes chemical examination of the 
urine (see p. 59), microscopic and bacteriological examinations of the urine, 
examination by means of direct X ray, by pyeloghraphy, by estimation of the per- 
centage of urea in the blood and iht function of the kidney in concentrating the urine 
and eliminating urea. 

For obtaining a direct X-ray examination of the kidney, the routine 
general preparation is carried out. The patient is kept on low diet for 
several dfays beforehand and an aperient is given, as described in the case 
of examination of the alimentary tract, followed by an enema if necessary. 
Means are taken to see that the colon is free from gas. A light breakfast 
may be given. 

Pyleography means the making of a photograph of the pelvis of the 
kidney. ITie history of the investigation of the urinary tract is very in- 
teresting. At first, ureteric catheters were used. These were rendered 
opaque by the insertion of ring^ of gold so that the position of the catheters 
was visible on X-ray examination. The next step was the use of coUargol, a 
substance opaque to X rays, injected by means of the ureteric catheters in 
order to tdmw the outline of the kidney pelvis. The next step was the dis- 
covery that substances with a large iodine content were opaque to X rays. 



FUNCTIONAL ACTIVITY OF THE KIDNEYS 213 

and could be administered in a form which was rapidly secreted by the 
kidney. Two methods of pyelography are described — (i) cystoscopic, and 
(2) intravenous. 

Cystoscopic examination is carried out in the X-ray department and 
utrcteric catheters are passed into the uteters. (For apparatus used see 
fig. 78, p. 188.) These are left in but the cystoscope is withdrawn. A warm 
solution of the opaque iodine compound is then injected by means of a 
syringe — the pelvis of the kidney will hold about 5 c.c. of fluid. As a rule 
the patient is not given a general anaesthetic, and the passing of the 
cystoscope and the ureteric catheters, and the injection of the fluid, may 
therefore cause some discomfort. The patient should be watched very care- 
fully, and asked to let the doctor know what sensations he experiences; a 
patient can usually tell when the ureteric catheter has reached the pelvis 
of the kidney. The injection of fluid may give rise to fairly considerable 
discomfort, due to the fact that the pelvis docs not hold as much as a 
normal one might be expected to hold, and in this case the physician will 
cease injecting the fluid. The administration of a mild analgesic, such as 
aspirin, will tend to minimize the fears and painful impressions the patient 
receives. 

The disadvantage of the cystoscopic method is the discomfort caused by it, 
and for this reason it is considered unsuitable for children or for nervous 
restless patients. 

The intravenous method is most useful, especially in the examination of 
persons who will not readily submit to the passage of a cystoscope. 
Patients suffering from inflammation of the lower part of the urinary 
tract would suffer considerable pain from the passage of a cystoscope. 

Intravenous pyelography is pyerformed by the injection into the circulation 
of a substance called uroselectan. It was first prepared by Professor von 
Lichtenberg, and is a non-irritating compound, containing a little over 
50 per cent iodine. It is secreted very quickly and docs not produce any 
toxic symptoms, and the urine in which it is contained is rendered opaque 
to X rays. As a rule about 20 c.c. are injected and an X-ray examination 
is made at intervals of 5, 15 and 30 minutes, when shadows of the kidneys 
and ureters will be seen (sec fig. 79, p. 189). If the patient refrains from 
passing urine, the outline of the bladder can be seen later; but, in order to 
investigate thoroughly the lower part of the ureter, the bladder should be 
emptied as opacity here obscures examination of the pelvic ureters. 

Urea concentration test. (MacLean’s test.) Investigation of the func- 
tion of the kidney is carried out during the treatment of medical and 
surgical conditions. In the former it is largely used as an aid to diagnosis. 
In the latter it enables the surgeon to determine any disability of the renal 
function and forms a preliminary investigation to any operation, par- 
ticularly those on the genito-urinary tract. After all operations, the blood 
urea rises, and the kidneys therefore require to be in specially good con- 
dition in order to perform the extra work put upon them, and should they 
Tail the patient may die of uraemia. 

Preparatim af the patient. A light cvcningimcal is given, and after this the 
patient is not allowed any fluid, medicine or ftx^. At a given hour the 
next morning, say 7 a,m., the patient passes urine, and this is saved in a 
Klass labelled 'No. i*. He is then given 15 grammes of urea in 100 c.c. of 
water. He passes urine at 8 a.m., 9 a.m., and 1 1 a.iq- — that is, i, 2 and 4 



214 SOME I><VESTIOAttONS ANS Tfi8t« 

hours after the administratiori of urea. These spedtttens are collected and 
and placed in glasses labelled ‘.Afar. 2, 3 and 4’. 

The luinc collected is examined — the normal amount of urea in urine is 
2 per cent. ; but, as urea acts as a diuretic, the urine obtained immediately 
after its administration will be more dilute and the first specimen may 
therefore be expected to contain only i .5 per cent., which is accepted as 
normal. The amount of urea will rise in the second spechnen, and the last 
one will contain the highest quantity, which should be a per cent. If the 
kidney is disabled, the percentage of urea found in the urine will be lower 
than normal, and will not rise in the later specimens as it should. 

Blood urea test. As a general rule analysis of the blood for its urea 
content is made at the same time as the urea concentration test. A speci- 
men of blood is taken before urea is administered, and at one or two 
intervals after its administration. 

The normal percentage of blood urea is 20 to 30 milligrammes per 
100 C.C., or 0.02 to 0.03 per cent. In uraemia, arteriosclerosis, acute 
nephritis, chronic interstitial nephritis and other conditions in which the 
kidney is disabled, it may be as high as from 200 to 300 milligrammes per 
100 C.C., or between 2 and 3 per cent. In chronic parenchymatous 
nephritis it is unusually low, below 0.02 per cent. 

Indigo-carmine dye test. An intravenous injection of indigo-carmine 
is found to render the urine of a normal subject a deep blue colour in from 
7 to to minutes or perhaps a little longer. This test is sometimes performed 
in the investigation of the renal function; if the time is delayed, or the 
colour only pale blue, the kidney is considered to be disabled. 

Renal efficiency test. (Van Slyke’s test.) In order to determine with 
comparative accuracy the function of the kidney with regard to the nor- 
mal constituents contained in urine and the presence of any possible 
abnormal constituents, particularly albumin, the following investigation 
is made. No preparation is necessary. 

First thing in the morning, whilst the patient is still fasting, his bladder 
is emptied by means of a catheter. The catheter is left in position, with a 
spigot placed in the fi-ec end. Exactly one and two hours later the bladder 
is evacuated and the specimens obtained are sent to the laboratory for 
examination. 


EXAMINATION OF THE URINARY BLADDER 

Cystoscopy. Examination of the urinary bladder by means of an 
instrument called a cystoscope is carried out in order to inspect the cavity 
of the bladder and the condition of the openings of the ureters which 
enter it. 

A cystoscope consists of a telescope, fitted with lensefl. An electric bulb 
is passed into the telescope. It is rather a large instrument, like a metal 
catheter, and is passed into the bladder through the urethra; as a rule a 
general anaesthetic is not employed; in the case of men an injection of 
percainc or novocainc is made into the urethra (see fig. 80, p. 19O). 

Preparation for examination. The instrument is sterilized — ^jweferably in 
formalin vapour, since this does not necessitate wetting. It may, alteiv 
natively, be prepared by separating the different parts and Standing them 



EXAMINATION OV THE URIMARY BLADDER 215 

in a tall vessel in lysol or spirit; the distal end, which contains the lenses, 
should not be covered by solution, as these will be fogged if fluid gets 
between them. The electric bulb should be tested to see £at it is working 
before the apparatus is handed to the surgeon for insertion into the 
urethra and bladder. A spare bulb should always be supplied. 

Method. The patient should be informed of the nature of the procedure 
and he should oe placed in the lidiotomy position. He must be covered 
so that there is the least possible exposure and his legs should be encased ih 
long woollen stockings. A catheter is passed and the bladder is emptied; a 
tubing and funnel are then attached to the catheter which is in the bladder 
and sterile lotion is run in — 5 to 10 ounces being used, in order to distend 
the bladder and enable the surgeon to see all parts of it. The lotion used 
should be warm. 

Sigmoidoscopy. For this investigation the instruments shown in 
fig. 81, p. 191 are required. The colon must be empty, therefore the patient 
is given an aperient two days before the investigation and 12 hoiurs 
beforehand the colon is irrigated. 

In some cases a general anaesthetic is given, but in the majority of cases 
the patient is given morphia gr. J half an hour beforehand. The examina- 
tion may be made with the patient in the left lateral position or kneeling, 
resting on the elbows. The instrument is supplied with an introducer; this 
is lubricated and it is then passed through the anal canal. The introducer 
is then withdrawn and the surgeon puts his eye to the lens, the electric 
power which illuminates the lamp is turned on, and the passage of the 
instrument along the rectum is carefully directed. 

GASTRIC ANALYSIS 

Analysis of the gastric secretion is carried out as an aid to diagnosis, by 
helping to discern the behaviour of the stomach, its absorptive powers 
and the condition of its secretions. The commonest method in use is by the 
administration of a test meal which aims at discovering the activities of the 
stomach during the process of gastric digestion. 

A fractional test meal, the method of Rehfuss, is mast commonly 
employed today, and the articles used for this (see fig. 82, p. 192) include: 
A Ryle’s stomach tube, a mild lubricant and a record syringe of 20 c.c. 
capacity. 

A pint of oatmeal gruel which has been prepared by putting 2 oz. of 
oatmeal into a quart of water and boiling it gently until it has been re- 
duced to a pint, and a feeder or drinking cup from which the patient tsikes 
this fluid. 

A sterile flask for the reception of the resting juice with a capacity of about 
half a pint; and a flask of similar capacity for the reception of the residual 
fluid. 

Eight to ten sterile test tubes numbered in order, into which 10-15 ^-c. 
of fluid from the stomach will be put every 15 minutes. Some physicians 
like a piece of filtering paper plac^ at the open end of each test tube, so 
that the fluid receiv^ is filtered at once. 

A towel is provided for the patient to place under his chin, and a 
rccciyer in case he feels that he is going to be sick. 



2i6 some investigations and tests 

The patient should be told the nature of the examination. He will not 
suffer any inconvenience from it and may be given something interesting 
to read so that his attention will be occupied; a woman might knit or sew, 
as she pleases. 

Method of administration. The test meal is given on an empty stomach, 
usually at an early hour in the morning, say at 8 or 9 a.m. The patient will 
have had a light supper, early in the evening, of a carbohydrate nature. 
Two or three hours after this he will be given one or two ch^oal biscuits, 
and should not take any other food or drink until after the test is carried 
out the following morning. 

At the time of the test the patient swallows the tube. It should be moist, 
but as it is usually brought to the bedside in a bowl of warm water no 
other treatment will be required. Some sisters use a small quantity of liquid 
paraflRn to lubricate the tube, though this is not necessary. The tube is 
put in at the comer of the patient’s mouth and he is encouraged to swallow 
it — put in in this way there is less likelihood that the tube \^1 impinge on 
the posterior pharyngeal wall which would make the patient retch. The 
end of the tube will reach the stomach when the first mark on it is at the 
level of the lips. The 20 c.c. syringe is then attached to the distal end of the 
tube and the contents of the fasting stomach, that is the resting juice is 
withdrawn; the quantity is noted, and it is put into the sterile flask labelled 
ready to receive it. 

The patient now takes the gruel; if he finds it difficult to drink a pint 
the nurse can pass some of it into the stomach through the Ryle’s tube. 
Specimens of about 10 c.c. are now, by means of the metal syrin^, with- 
drawn every 15 minutes for two to two and a half hours, until eight to ten 
specimens have been obtained. These are placed in the test tubes ready 
numbered. At the end of this time, if the stomach is not empty, the re- 
mainder of the contents are withdrawn and put into the flask labelled 
'Residue'. The tube can then be removed, and the patient may be given a 
mouth-wash and a suitable feeding or light meal. 

Investigations which will be made as a result of this test will prove: 

(1) The amount of resting juice; in the normal this is from 60-120 c.c. In 
abnormal conditions it may be very much increased and in carcinoma it 
may rise to 400 c.c. 

(2) The amount of hydrochloric acid present. 

(3) Any charcoal present. Charcoal should have been passed oflf during 
the night, and its presence will show delay in the activity of the stomach. 

(4) Excess or absence of hydrochloric acid. In the absence of HCl, lactic acid 
may be present. 

(5) 7 %? odour of the specimen — particularly any foul odour, which would 
suggest dilatation of the stomach. 

(6) The amount of residue. A large amount would indicate that the 
stomach is very slow in emptying. 

The colour should be not^ — ^whether clear or not, and whether it 
contains bile, showing that there is regurgitation from the duodenum, 
or blood, which indicates oozing from the stomach, or any excess of 
mucus. 

The method of gastric analysis described above — ^a fractional test meal— 
also gives information regarding the degrees of acidity at different inter*' 
vals; the time when bile, blood or CKcess mucus may appear, and the time 
the stomach takes to empty. 



GASTRIC ANALYSIS 217 

Alcohol, injected by means of Ryle’s tube, is occasionally substitut«l 
for gruel in a fractional test meal. Only loo c.c. of seven per cent, alcohol 
is employed as compared with 500 c.c. of gruel. Samples of stomach 
contents are taken every half-hour for one and a half hours. 


Ewald’s test meal. Other less often used tests for gastric analysis 
include Ewald’s. In this test the patient is given a slice of dry toast and a 
cup of tea without sugar or milk on a fasting stomach. A stomach tube is 
passed and the meal removed after an hour or so. 

Boas’s meal consists of half a pint of gruel passed into the stomach and 
removed in thirty minutes. (The method of passing a stomach tube has 
been described in the administration of gastric lavage, on p. 135.) 


Histamine is used in examination of the contents of the stomach in 
order to make a differential diagnosis between a true and a false achlor- 
hydria; it is a most powerful stimulant to the secretion of HCl. The 


qASTJilC, 

ANALYSIS 


Cashu lUctr 
MtStUif Juice 
400 cx. 


Mormal ^Stomach 
Resting Juice 
60 cx. 


Pernicious 
Antsmia. 
Resting Juice 

6 c.c. 


SO W7)\ 

BO 02SZ)^ 

) 10 {.-255) 
j6d‘ 

SO ('J82)^ 

30 (•/0^lLU==JL. 

) io 

y {%HCL} 


2i in 5 horn 

Residual 
rluid 600 c 
due io 
obstruction 



Normal 

■y^(Stomach empty) 


Stomach rmphj in Perniciou s 


S SB 

L Starch \mSlood 
I, .1 starch 


B Arurmia 


D / 

I ^BtU 


Fio. 85. — Chart showing Gastric Acid Curve — in a case of Gastric Ulcer Compli- 
cated BY Pyloric Obstruction — in a Normal Stomach — and in a case of Pernicious 

Anaemia. 


stomach is prepared as for a fractional test meal, the fasting juice with- 
drawn, and the stomach washed out with plain water. A hypodermic 
injection of liistamine, 0.5 milligramme, is given and half an hour later 
from 10 to 15 c.c. of gastnc fluid is withdrawn and tested. The absence of 
acid, determined by using Giinzberg’s reagent, confirms the diagnosis of a 
true achlorhydria such as exists in pernicious anaemia. 

Histamine is a poison which causes a sudden fall in blood pressure; it is 
therefore used with caution in piemicious anaemia, a disease in which the 
hlood pressure is usually low. 

GLUCOSE TOLERANCE TEST 

Since the blood always contains some sugar, it can reasonably be 
t'xpccted that its sugar content will be highest immediately after a meal 



2i8 some investigations and tests 

rich in carbohydrates, and lower several hours after a meal, and lowest 
when fasting. 

In a normal person the fasting blood sugar is about o*o8 to 0*12 per cent., 
the resting blcxxi sugar being about o-i2 to 0-15 per cent. After rapid 
absorption of glucose there is a quick rise in blood sugar up to just below 
the renal threshold — this on the average is o*i8 per cent. At this level the 
insulin factor, or the mechanism which controls the storage of sugar in the 
body, comes into play and prevents the percentage of blood sugar from 
rising above the renal threshold limit. Instead, it begins to fall steadily and 
gradually until the resting level is again reached. 

The renal threshold is the term used to describe the maximum percentage 
of blood sugar possible without its being secreted in the urine. It is also 
sometimes described as the leak point of the kidn^, meaning the point, or 
percentage of blood sugar, at which sugar would begin to leak out of 
the body by way of the kidney. The accompanying chart shows what 



_ aA,-*,-/ ^ in severe 

-^Normal 


Fig. 86 . — Showing the B1.00D Sugar Curve consequent on a Glucose Tolerance 
Test in a Normal Person and w a Case of Severe Diabetes. 

actually happens in a normal subject when a dose of glucose is given 
in order to test the function of the sugar controlling mechanism of the 
blood. 

In diabetes there is deficiency of insulin with the result that the storage 
mechanism is disordered. There is, therefore, no control, and varwng 
degrees of hyperglycaemia occur after the administration of glucose. The 
accompanying chart shows a blood sugar curve in a very serious case of 
diabetes, as compared with the normal. The fasting blood sugar is 0*20 per 
cent. — in half an hour it rises to 0-36 and after one hour reaches a maximum 
of 0-44 per cent. It then begins slowly to fall. 

Comparison with the chart demonstrating the behaviour to be expected 
in the normal subject shows that the resting blood sugar is 0.08 pier cent. — 
it rose to o. 1 7 per cent., which is below the renal threshold margin, and fell 
quicUy. At the end of two hours it is seen to be almost as low as at the 
starring pioint, which demonstrates pierfect functioning of the sugar-con- 
trolling mechanism. 



GLUCOSE TOLERANCE TEST 2 1 9 

The test is carried out as foilows— A sample of the patient’s blood 
is taken before breakfast when he has fasted all night. He is then given 50 
grammes of glucose in 100 c,c. of water and specimens of his blood are 
taken at half«hourly intervals for the next 2 hours; three specimens of 
urine are taken at hourly intervals. In the normal subject the fasting blood 
sugar may for example be o-l2 per cent. — ^within half an hour it will rise 
to just below the renal threshold. It may rise to ot 7 per cent., but will then 
begin to drop quite rapidly and in two hours will have fallen to the resting 
level again. 



Chapter 14 

The Application of Splints, Plaster of Paris 
Extensions and Strapping 

Types of splints- — Plaster of paris — The me and application of extension — 
Skeletal traction — Splint and plaster sores — Closed plaster method — Application of 

strapping 

S plints are rigid structures employed to give support and protect the 
parts of the body to which these are applied. In an emergency a 
splint may be made of any fairly stiff material. Cardboard, wo^, 
walking sticks and umbrellas are commonly used as emergency splinting. 

The splints used in hospital may be of light metal, aluminium, or 
malleable iron, of poroplastic felt or of wood, leather or steel. Plaster of 
paris is a very favourite splint as it can more easily be modified and 
adapted to the body, and can also be prepared in a variety of thicknesses 
and degrees of strength. 

TThe side of the splint which is to be placed next to the body is usually 
padded, either with felt or wool in the case of metal splints or by a 
specially prepared padding stitched on. The articles required and the mode 
of procedure in padding a wooden splint are illustrated in fig. 91, p. 225. 

The padding of a splint is designed to prevent pressure of the harf 
framework of the apparatus, which is bandaged to the affected part, from 
injuring it and the padding must be adequate for this purpose; the sides, 
ends and edges of the splint must be covered and when the splint is 
applied the nurse should examine it to sec that these parts are covered 
and not pressing into the skin. 

A nurse should be familiar with the splints in use in the hospital in which 
she is working and know how to apply them. Many splints are named after 
the surgeon who designed them: such arc the Thomas’s leg splint and 
Hodgen’s splint which are shown in fig. 88, p. 222. Other well-known 
ones are Carr's, Neville’s and McIntyre’s splints. Splints arc also described 
according to their shape as straight, angular, gutter splints, &c.; others arc 
designate according to their use as a cock-up splint for the hand, a 
talipes splint, an angular foot and leg splint and so on. 

Plaster of paris splints are made by using muslin bandages into 
which fine dental plaster has been rubbed, the bandages arc then rolled 
loosely and after being soaked in tepid water arc applied wet to the part; 
the plaster sets fairly quickly, in a few minutes, and the splint dries and 
hardens. (Sec figs. 93-102, pp. 227-230.) 

The articles needed to apply plaster of paris arc shown in fig. 92, p. 226. The 
part for which the splint is intended should be shav^ the plaster is 
directly applied to the skin; but when the skin is first protected with a 
layer of wool, a domettc or lint bandage shaving is not necessary. Wh^en 
preparing the patient the nurse should protect Sic floor around the bed 
and the patient’s bedclothing atid personal clothing with dust sheets for 
fear lest splashes of wet plaster should fall on these. 


220 












THE ATPUCATION OP SPLINTS 823 

Those handling the plaster will usually wear gowns to protect their 
clothing and gloves to protect the nails and skin of the hands (since 
plaster of pans makes the skin dry and uncomfortable). 

Tepid water should be supplied for soaking the bandages; hot water 
delays setting and cold water makes the phater set too quickly. When 
soaking a plater bandage it should be placed carefully into the water 
(which must completely cover it) ; it will be soaked through when bubbles 



Fjo. 89. Aeroplane (Ajui Abduction Splint) in Kramer’s Wire. 



Fio. 90. — Tiie Same Type of Splint as Fio. 89 Padded. 

of air cease to rise to the surface of the water. It should then be carefully 
lifted out — if the nurse will take hold of the bandage, using both hands, 
and gently compress the ends, this will prevent the vtJuablc plaster from 
slipping out into the water. The bandage, liaving been lifted out of the 
water, should be very slightly twisted; the free end should then be loosened 
and the bandage handed to the operator for application. (See figs. 94 and 
95, p. 227.) A second bandage should be placixl in the water — ^it is letter 
to place each bandage in as the soaked one is taken out, as this gives time 
for the bandage to be thoroughly wet. When a bandage is sJlowed to 
remain in water too long, it will become so loose that it is difficult to 
handle, and the plaster will set and stick to the bottom the bowl. 



224 APPLICATION OP SPLINTS 

Plaster of paris bandages cost several pence each and wastage should, as 
far as possible, be avoided. 

In the application of plaster of paris strengthening bands and pads 
can be incorporated as needed, over the flexures of joints for example, 
where strain may be experienced. These arc prepared as shown in figs. 96 
and 9.7, p. 228. Another method of strengthening the plaster sphnt is 
by the incorporation of malleable iron splints, and strips of metal. 

When finished the surface can be made smooth by moulding the wet 
plaster with the hands, by the addition of plaster of paris paste made by 
mixing some loose plaster with water. When quite dry the surface may be 
polished with talcum or varnished with some rapidly drying varnish. The 
provision of a smooth surface renders the plaster less liable to injury and 
wet. The edges should be trimmed with the plaster knife provided. The 
date of op>eration and/or application of the plaster and the length of time 
it is to be worn may be written on the plaster (see fig. loi, p. 230). At the 
same time the plaster is marked where it is to be cut for removal. Fig. 1 02, 
p. 230, shows Ae method of handling plaster shears. 


THE USE AND APPLICATION OF EXTENSION 

Extension by one means or another may be applied to almost any part 
of the body, more usually to the limbs and the head. The object of this 
form of treatment is to effect greater immobilization than can be attained 
by the application of splints or plaster of paris. 

Immobilization by means of extension is employed : 

(a) to correct deformity by overcoming the spasm of large muscles 
recently subjected to injury as in the case of a fracture of a limb, or 
muscles irritated by the existence of disease as occurs in tuberculous 
affections at joints. 

(b) to maintain the correction of deformity produced by reduction of a 
fracture or dislocation. 

(c) to prevent pain, such as may occur when the diseased parts of a 
joint rub together as occurs for example in tuberculous joint 
disease. 

The commonest methods of applying extension to a limb arc: by 
traction on the skin as when adhesive plaster and Sinclair’s glue arc used, 
and by skeletal traction when some form of apparatus is applied to part of 
the skeleton below the affected part. 

Strapping extension. The articles required for this application arc 
shown in figs. 103 and 104, pp. 231-2. The skin of the leg should be shaved, 
the strapping extension prepared to fit the patient for whom it is intended, 
either of the two varieties of extension shown in fig. 104, p. 232, being 
employed. When a Thomas’s splint is used the separate strips of strapping 
placed one on each side of the leg arc used — the strapping is notched as 
shown, lampwick is used to obtain the pull from the lower end — ^notethetwo 
different ways in which this may be fixed to the strapping; in one instance a 
loop of strong holland tape is sewn on to the end of the strapping and the 
lampwick fastened by means of a nautical knot; in the other the lampwick is 
stitched to the end of the strapping. The strapping extension is then applied 
as shown in figs. 105-106, pp. 233-234. Note that the malleoli are not 



225 






Am.ie 





Fic. t| 2 . — see pa^e 220. 
lIpptLR Shelf. i\') Plaster «)f paris ban- 
dages. (B) Powdcrcti plaster of paris. 
(C) Plaster knives and scissors. (I>) C lotion 
wool bandages, i P) Lint bandages. 1 F) Roll 
of stockinette. 

Low'ek Shelf. I>ust sheets and protec tive 
clothing for the operator. Article's for 
shaving the skin. Large bowl Utr pail) for 
tepid water. 



227 



I k;. 93. scf pages 220-4. Making; Plaster Bandages. 
I inr dVnlal plaster of paris is rubbed into the meshes: 
the barulatajes are lightly rollcrl and stored in tins. 



Fk;. 94, 

Pi'TTiNc; A Pi aster 
BandagiE in to Soak. 
A dark thread is run 
through the free end of 
the bangage in order 
that the end may \w 
more easily distinguished. 



Fig. 93. 

When the bandage is 
soaked it is lifted out, the 
ends are slightly com- 
pressed before the band- 
age is handed to the 
operator. 

The nurse, in handing a 
plaster bandage slightly 
Uxisens the free end. 


Fig. 96 . — see pages 220-4. 

A pad or slab is made by soaking a bandage and carrying it backwards 
and forwards as shown. 



Fio. 97* 

The completed slab ready to be 
handed to the operator. 


229 



98 . — see pa^es 220-4. 

Using a plaster of paris slab to make an anterior plaster case. 



The plaster slab (in Fig. 98) in 
position on the patient 


1C patient. plaster case 

[Photo umphs are kindly lent by Mr, F. P, Fitzgerald) 


The completed anterior 
plaster case. 


230 



Fig. ioi . — see pages 220-4. 

Tlie date of operations, and the time the plaster 
is to be worn is written on it with indelible pencil. 
The plaster is marked where it is to be cut. 







Fio. 102. 

Cutting along the line on a marked plaster with 
plaster shears. 


231 





Fk;. io;^. see pai^e 224, 

LJppek Shelf, Strapping rxtrnsioii a.s in Fig. 104. 
Hot water to warm (he strapping. Splint wx>ol, 
bandages, needle and cotton. 

Lower Shelf. Articles for shaving the skin, 
weights, bed blocks. 

A Thomas’s leg splint is shown ready prepared 
with bandage slings, for the leg, held in |K)sition 
by clips. 



232 



STKAmNcEjpriMsieN |pF 

HH ‘f- 




V 

I 








F’k;. see poiies 22^ and 2.\i . Stkappinc; Mx j knsion.s. 

'Fhc prt'parcd strapping extension at the top of the picture has a strapping 
spreader inserted. This is made of wood, w ith a hole in the middle through 
which cord is passed for the suspension of wtdghts. This metlKHil of strapping 
extension may be employed in ('onjunction with a laslon splint or with 
Hodgen's or I'homas’s splint as shown in Fig. io 8 . 

The other examples given above are those employed when hxt'd skin traction 
is used. Idle ends of the strapping are then tied to the low er end of either the 
Hodgen's or the Thomas’s leg splint. 

In the lower of the two examples a piet e of lamp wick is firmly stitchcxl to 
the end of the strapping; in the other a firm I(M)p is stitched on and the lamp 
wick is knott(‘d through this loop. Lamp wick is used bet ause it Is strong, 
firm, and does not slip. fSVr also Figs. lo^-fi.) 



233 



1 


Vk;. 105. —iff pag,es 224 and 241. 
Appi,i(;atk)n oi- STRAPiMN(i Extension to Leo. 
RuiMT Leo. i\ bandage is applied over the fcK)t and 
malleoli to protect the bony prominence.s. 

Leit Leo. The strapping exteasion is in pixsition and 
adherent to the skin of the leg. The bandage, as .shown 
on the right leg, is now carried up. over the strapping 
(sec next figure). 





Fig. i(} 6 .—see pages 224 and 241. 

Application of Strapping Extension to Leg. 

Left Leg. This shows the strapping cxtcasion illustrated in Fig. 105. It is 
now covered by bandage. Note that the strapping has been turned down at 
top, below the knee, sticky side outwards. The bandage is carried round over 
the sticky strapping which prevents the bandage slipping. 


235 



Fk;. 107.- - page 241. (A) Kirschncr’s drill and wire, stirrup 
and hook, wire cutters and instruments for tightening nuts. 
(B) Icetong calipers. 

When skeletal traction was first employed almost invariably ice- 
tong calipers {see B above) were used. The points of the ralip>ers 
are inserted into the cancellous tissue of the bone, but there is a 
tendency for these to slip and in time experience showed that 
th(‘ use of a pin or w ire passed through the end of the l>one was 
preferable. It is more comfortable and there is no chance of the 
pin slipping. 

rhe pin is sterilized and bored through the bone by a drill. The 
ends of the pin or wire are then fixed to a specially made stirrup 
and from this, cord is carried to pulleys placed on the special 
h<‘d apparatus. Weights are suspended from the cord. 

The pin or wire is firmly attached to the stirrup and made 
secure by having the nuts tightened up. When prop>erly applied 
the pin docs not slip and there is little dLscomfort even at the 
beginning of the treatment. 



Strapping Extension 





Fig. iog,ste page 241. 
The same patient as in Fig. 108. 
Note the physical ctiort the 



238 



Fig. no. — see page 103. 

Strapping applied to knee, as in applying Scott’s dressing. 
The position of the patella is shown. 



Fu;. III.- w page 243. 
Strapping ap])lied to the 
foot after Goldthwaite’s 
method. The first turi) is 
round the metatai^als, 
the second up over the 
internal arch and the 
third round the ankle. 
I’he arrows indicate the 
direction of the strap- 
ping. The effect of the 
strapping in supporting 
the arch can bv seen. 



239 



I'Ki. I r->. -Sl KAlM lNG OK ChESI . 

Note that, for the purpose of deinonslratioii, the vertebral spines 
arc marked. The strips of strap{)ing are all ])repared. .\pplication 
is Jtiade from below upwards, over th*‘ lower ribs first, with the 
chest in full expiration. Each strip must extend from beyond the 
spine (as shown) at the back, round the ehest, and to the opposite 
side of (that is beyond) the sternum in front. 

The operator fines f)ne end of the strip of strapping over the spine by 
placing her fingers on it (as shown). She then gets the patient to 
breathe in and then out. The patient must empty the chest as much 
as po.ssible and is instructed to blow the air out of his chest. The 
operator says “continue blowing, go on, right out” until she is 
assured the chest is as empty as possible. She then, w'ith her othcr 
hand, carries the free end of the strapping round the. side and front 
of the chest where it is firmly fixed. The sulrsequent layers of 
strapping are then applied. {See f’ig. 1 13.) 


240 



Fu- 1 13.— Strapi'Inc; of Chkst. 

When the chest is strapped, a strip of strapping 
is j)laeed, vertically, o\ er the ends of the strips, 
back and front, in order io prevent the ends of 
the strips l>eing disturbed. 

The patient is not allowed to raise his arm 
when his chest is being strapjx^d, becau.se 
raising the arm would interfere with full 
expiration. The object of strapping the chest is 
to prevent the full range, of respiratory move- 
ment. , 

In Fig. 1 12 the arm of the patient is being held 
out of the way by an a.ssistant. But notice that 
the arm is merely held away from the chest 
wall; it is not elevated liecause raising the arm 
would partly fix the ribs and full expiration 
would then be difficult. 


USE A.ND APPUCATION OF EXTENSION 24! 

covered by strapping, but that a layer of bandage is first placed round the 
ankle to prevent the edge of strapping from impinging on the skin. The 
extension is placed fairly well back on the leg so that the foot is not plantar- 
fiexed by it — having the strapping forward produces this deformity and it 
is an error commo^y made. In order to render the strapping sticky the 
back of the plaster should be placed against a jug of hot water, laid over a 
radiator or held in firont of a fire. Turpentine should not be used as it 
irritates the skin. 

When the form of strapping extension with a spreader and cord is 
employed, weights are used. Fig. 1 04, p. 232, showing a patient in bed with 
this extension applied, indicates the use of weights, and fig. 108, p. 236, 
gives some idea of the extent a patient with a fractured femur (for 
example) may help himself. 

Skeletal traction is very commonly used today. The extension appara- 
tus shown in illustration, fig. 107, p. 235, is employed. Either a transfixion 
pin, or more rarely ice-tong calipers, are used. 

For application of transfixion pin the skin should be prepared, and as 
the sterilized pin is bored through the bone by a drill, a local or general 
anaesthetic will be needed. A sterile dressing is placed round the points 
of insertion of the pin on the skin and traction is made by fixation of the 
ends of the pin to a specially devised stirrup-shaped apparatus, from the 
base of which cord is passed over pulleys on the special apparatus attached 
to the type of bed employed and, by means of weights, extension is made 
on the limb. Either a Thomas’s knee splint or a Hodgen’s splint is 
employed with slings attached by means of clips (see illustration, fig. 108, 
p. 236) in which the limb rests as in a hammock. 

Special points in nursing patients wearing splints, plaster or extensions. The 
general attitude of the patient should be watched and discomfort relieved 
whenever possible. A small pillow under an arm or leg, in the nape of the 
neck or the small of the back may help. Cradles should be employed when- 
ever possible so that the weight of bedclothes does not rest on a splinted 
limb. 

The extremities should be watched for indication of interference with 
the circulation to a limb particularly. The toes and fingers should be 
warm and not blue and cold after a splint or plaster has been applied. 
It is impOTtant to avoid footdrop; the heel should not rest on a splint, nor 
the foot hang over so that the tendon of Achilles is made sore. 

The nurse should be very familiar with the effect the surgeon desires to 
obtain by any application the patient is wearing and see that this is not 
interfered with, the slightest alteration of the position of a splint or any 
movement of an extension appliance being reported without delay. When 
weights are employed thoe must hang free of the bedstead; the treatment 
will be interrupted for example if the weight rests on the bedstead or even 
touches it, or rests on the floor. 

SPLINT AND PLASTER SORES 

When any fixed apparatus is badly put on, sores may be caused, either 
because the apparatus is inadequately or ba«ily padded, or it may be too 
loose or too tight, the p:i^ure being unevenly or too t^htly applied. 

Sometimes a patient will imagine he is called upon to bear any discom- 
fort which comes his way; the application of a splint or plaster of pans is 



242 THE APPLICATION OP SPLINTS 

one of the occasions when he should be warned about this, and asked to 
report any discomfort, so that it may be investigated. Children are the 
worst offenders, as they so quickly get used to discomfort that sores may 
arise without the making of any complaint; and the first indication the 
nurse has of the condition Is an offensive smell or discharge. But children 
who are uncomfortable are often restless at night, and such an occurrence 
should never go unreported in surgical nursing. Once noticed it should 
be investigated. 

In some cases discomfort or pain due to pressure soon results in tingling 
and burning sensations, and swelling of the distal parts will occur if the 
pressure is uniform over the circumference of a limb. 

Treatment. Many splint appliances have, by the nature of the treat- 
ment required, to be tightly applied, as for example when correction of 
any deformity has to he made. But if one spot becomes painful, attempts 
should be made to relieve pressme at that point for a time — the use of a 
small ring pad of wool may be tried though, as the putting of wool 
between a painful spot and a splint usually increases the pressure, such 
relief is often only temporary. The nurse had better try to distribute the 
pressure more evenly and, if dhe cannot alter the bandages for this purpose, 
she should have everything in readiness for the surgeon to do so when he 
next visits the ward, or even request him to come for this purpose. 

CLOSED PLASTER METHOD 

Mr. Winnett Orr duringthewar ofi9i4-i8 taught the value ofrestin the 
treatment of wounds by enclosing the wounded limb in plaster of paris. 
After the war he continued to work and experiment and write, and to 
him is ascribed the principles of the ‘closed plaster method’. During the 
war in Spain Dr. Trueta demonstrated to the world the advantages of 
this method. 

Principles. Cases must be treated early ^ within six hours, before serious 
infection has become established. 

Debriderrwnt, which includes removal of all contused tissue, blood clot, 
injured muscle that seems to be inelastic when touched, is absolutely 
essential. (See note below.) 

Given these conditions any wound may be encased in plaster of paris. 
Blood and dischai^ soaks through the plaster which may become very 
smelly. 

Nursing Points. Keep the limb ivell elevated. Watch the colour of the toes 
or finger ends which are always left exposed. Note whether the patient 
complains of pain, or numbness and tingling. Observe how quickly the 
plaster becomes soaked, and the odour. The temperature will usually rise 
and should be watched, but unless accompanied by signs of toxaemia it is 
not considered important. Upon these points being accurately observed 
and reported, the surgeon will determine how the case is progressir^ and 
whether interference with the plaster is necessary or not. 

The ‘closed plaster method’ is not considered satisfactory when cases are 
not treated early; when infection has undoubtedly invaded the fascia 
covering muscles and local debridement is impossible. In such cases dead 
muscle tissue is present and there is danger of gas gangrene and with the 
‘closed plaster method’ this danger would be greater. 



APPLICATION OF STRAPPING 


243 


APPLICATION OF STRAPPING 

It may be necessary to shave the skin before applying strapping. 
This point should be considered. Holland-backed a^esive strapping 
should be warmed to make it adhere better. Zinc oxide strapping is 
adhesive. No creases or wrinkles should be allowed as these cause 
soreness. When strapping is applied round the circumference of a limb 
it must be firm and even but not tight. After application the extremities 
of the limb should be examined to sec that the circulation has not been 
impaired. 

Elastoplast is frequently used as a support and to retain dressings in 
position as an alternative to strapping. It is pliant and slightiy elastic. 
When applying elastoplast it is important to maintain a slight, even 
stretch on the material. When taken round a limb the tension must be 
very even. 



CImpter 15 

Bandages and Bandaging 

Types of bandages — Materials used in bandaging — Rules for the application of a 
roller bandage — Examples of bandagmg — Tnan^ar bandaging 

T here arc varieties of bandage, examples including the roller bandage 
made from strips of material of convenient lengths and from half an 
inch to eight inches wide. These bandages should be prepared with- 
out selvedge; in many cases raw edges are used; in the woven bandages 
the edges are firm but not hard. A roller bandage should be closely and 
firmly rolled, with all the edges even. 

The triangular bandage or sling is made by taking a square of material; 
for a large sling a piece 40 inches square is chosen. If this is folded over 
once triangle-wise and then cut across, it will make two bandages. A 
triangular bandage is described as consisting of a long side — the base — 
opposite to which is the point or apex, and two short sides and two ends 
(see p. 256). 

Special bandages include the T-shaped bandage, plain and many- 
tailed binders and the four-tailed binders. A T bandage is made by taking 
two strips of material, from 4 to 5 inches wide, and stitching them to- 
gether in the form of the letter T. It is used to retain dressings on the 
perineum. In the case of a male patient the strip of material carried up in 
front of the pubes is divided into two, one being placed on each side of the 
scrotum, in order to avoid discomfort. 

A plain binder is made by stitching two strips of material together, so 
forming a double layer. It should be sufficiently long and wide to retain a 
dressing, or to give support to any part of the trunk to which it may be 
applied. 

A many-tailed binder or bandage, the bandage of Scultctus, is made by 
stitching strips of material together in the middle third of their length, 
leaving the ends on either side free, in tail formation. 

A many-tailed bandage can be made in an emergency by tearing a 
piece of material into shape, and it is useful, for example, when a limb is 
to be bandaged which may not be raised or lifted from the bed; the ban- 
dage, with the tails at one side rolled or folded up, can be slipped under the 
limb by pressing down on the pillow or mattress on which it lies; then, 
by taking the tails across in front of the limb, a dressing may be retained 
in position and changed without movement of the limb. 

The four-tailed bandage is made by taking a piece of material of the 
desired length and width and tearing it towards the centre to form four 
tails (see p. 251). 

Materials used for bandages. Cotton, linen, muslin, gauze and calico 
are fairly cheap materials. Flannel, flannelette and domette are warmer than 
cotton, a little firmer and more expensive. Cripe material is used where 
slight elasticity is required and elastic and rubber bandages where 

*44 



BA.NDAOB8 AND BANDAGING 245 

firm support is needed. For warmth and protection lint, or coUm wool 
bandages, are used. Starch, and plaster of parts bandages are employed 
where a very firm surface is required to act as a splint. 

Some of the uses of a bandage have been outlined as the materials 
employed were named, but, in addition, the uses of a bandage may be 
classified as follows: 

The provision of support and protection. 

Retention of splints, dressings and other apparatus in position. 

Retention of a limb in some definitely fixed position. 

Prevention of swelling by firmness of the application. 

To arrest bleeding, as when an Esmarch’s rubber tourniquet is em- 
ployed. 

To lessen external sources of irritation and so to relieve spasm. 

The application of firmness in bandaging may also lessen muscle spasm. 

Rules for roller bandaging. A neatly rolled bandage of correct length 
and width should be chosen, and held firmly in the hand. The operator 
should stand facing the patient at one side of the bed and, unrolling several 
inches of the bandage, place the unrolled material against the skin of the 
patient in an oblique direction, from within outwards and from below 
upwards in the case of the limbs and chest, and from above dowaiwards in 
bandaging the abdomen, unless an ascending spica of the hip is incor- 
porated, in which case the direction will be from below upwards. The 
reason for the direction given above is that the bandage fits better and is 
more easily retained in position by covering first the slimmest parts. The 
bandage should be held in the right hand when bandaging the right side, 
and in the left hand when bandaging the left side, and a nurse should be 
able to bandage equally well with either hand. Pressure should be applied 
\'cry evenly, and to effect this the bandage is unrolled in contact with the 
skin of the patient or with the dressing which is to be covered — a bandage 
should not be unrolled first and then dragged round the part to which it is 
applied, as this would result in creases or wrinkles and would thus provide 
a very uneven pressure. 

As a general rule two-thirds of the preceding turn are covered by the 
oncoming turn when bandaging a limb, and half the preceding turn is 
covered when bandaging the head. A pattern, such as is made when a 
reverse ascending spiral, or figure of eight is employed, should be arranged 
to lie on the outer side of the limb unless contraindicated, for example, by 
a wound in this situation. A pattern should never lie over a wound or over 
a bony prominence because the greatest pressure falls where the bandage 
crosses as in the formation of a pattern. Any pattern should be evenly 
spaced, one above the other. 

In bandaging a limb for the purpose of retaining a splint in position, it 
is inadvisable to cover the fingers or toes; if these are left free they can 
easily be inspected for changes in colour and temperature when the ban- 
dage is complete. 

Modes of application of a roller bandage. A bandage may be 
applied in circular turns as when one turn covers the other completely; this 
may be used on the neck or trunk, but circular turns round the limbs tend 
to cause constriction and, with the exception of an occasion when a ban- 
dage is used as a tourniquet, should not be employed for fear of interfering 
with the circulation in me limb below the bandage. 



BANDAOES AND BANDAGING 


246 

A simple spiral bandage is conunenced by placing the tail of the bandage 
against the limb in a direction from above downwards; the bandage is 
then carried round the limb and upwards and outwards — so fixing the 
bandage which is then carried up the limb in a series of spiral turns. 

A reverse spiral is begun in the same way to fix the bandage but, as it is 
carried round the limb from within outwards, the bandage is tiuned down 
on itself as it passes over the middle and outer third of the anterior aspect 
of the limb, which results in the formation of an inverted V pattern on 
the outer aspect (see figs. 1 14 and 1 1 5). IHie thumb of the free hand is used 
to steady the bandage as the reverse turns are made. 

A Jigure of eight is commonly employed when bandaging over a straight 
joint, or one which is not required to be moved. A figure of eight bandage for 
the knee joint when extended is shown in figs. n6 and 117 — the mode 
of application being indicated by arrows. 

(Bandaging is so essentially a subject which can only be taught by 
practical demonstration, that no attempt is made to describe the movements 
in detail. A number of illustrations are appended which may help the 
student nurse in her practical work.) 

Bandage for hand and forearm. A and B. In the first illustration 
(fig. 1 1 4) the bandage is carried obliquely, from the radial to the ulnar 
border as indicated by i, around the fingers — 2, and up over dorsum of 
the hand — 3; the head of roller, indicated as 4, is carried down over 


I 



Ffo. 1 14 . — Bakdaob foe Hand and Fio* 115* — Bandage for 
Forearm. Hand and Porearm. 


tm TO CoM- 
rr Bandage. 


F] 



24B BANDAGES AND BANDAGING 

dorsum of hand in illustration (fig. 114); it is then taken round palmar 
aspect and upwards to the ulnar side of wrist, as 5. Three circular turns 
of an ascending spiral are made round wrist as indicated by arrows. The 
first ascending reverse spiral turn is indicated as 9. The mode of reversing 
the bandage is shown at the last turn, the point at which the bandage is 
reversed on itself is indicated as X. 

Bandage for foot and leg. A. and B. This is similarly arranged and 
the direction of the turns is indicated by figures and arrows. (In bandaging 
a hmb, a figure of eight is employed over a joint which is extended and a 
divergent spica over one which is flexed (see next figures). 

In a divergent spica, application is made as shown in figs. 120 and 121, of 
the elbow and ankle. In both instances the tail of the bandage is first laid 



Fio. lao. — Divergent Spica Applied to Elbow. 

obliquely across the joint from within outwards, and then carried over the 
apex as indicated by i . It is then carried alternately below and above the 
joint leaving only half the preceding turn uncovered at first, and in the 
turns made later one third is uncovered. The direction of the bandage is 
indicated by arrows. 



Fio. 121.— Di\'eroent Spica Applied to Ankle. 

An ascending spica of the shoulder (see fig. 122). The tail of the 
bandage is placed obliquely on the shoulder in a direction from before 
backwards and downwards as i, it is then taken round the arm and 
brought up on the inner side. The bandage is then carried across the 
shoulder, over the upper part of the scapula and across the back to the 
avllla of the opposite side, across the fi-ont of the chest (see turn 2) and is 
continued over the shoulder; and the turns are repeated as often as neces< 
saiy in order to cover the dressing. The bandage is finished as shown 
overleaf. 




BANDAGES AND BANDAGING 


249 



Fio. 122 — Ascendino Spica Applied to Right Shoulder. 

A descending spica of the groin. The tail of the bandage is laid 
obliquely in a direction from below upwards, as shown in fig. 123. The 
roller is then carried round the back of the trunk to the opposite side and 
brought forward again as 2 in fig. 124. It is then taken over the outer 



Fio. 123. — CknnatNOBUBNT of Dbscbnoino Fio, 124. — DgscENOiNO Spica Of Right 
Spioa of Rioht Hip. Hip Shown CoMPuraED. 


250 BANDAGES AND BANDAGING • 

aspect of the thigh and round to the groin where it exactly covers the tail 
of the bandage shown in fig. 124. The first complete turn is indicated by 2 
in fig. 124, subsequent turns by 3 and 4. 

Bandage to cover an eye. In both illustrations the right eye is 
covered. A pad is placed over the closed eye; the first turn of the bandage 
is carried round the head in the direction indicated; the second turn is 
carried over the occiput at the back of the head and brought under the 



ear and up over the cheek as shown — this turn is then carried up on to the 
side of the head as indicated by 2. Subsequently, turns 3 and 4 are applied 
as indicated, and the bandage is completed by another circular turn, over 
the first one, around the head. 

When it is considered undesirable to cover the pad over the eye com- 
pletely, as, for example, in patients who are undergoing frequent treatment 
to the eye, a bandage may be applied as shown in fig. 126. 

A bandage to cover an ear may be required after an operation such 
as radical mastoidectomy. In fig. 127, the left ear is shown covered; in 



Fio. 127. — Bandaob to Cover Lxrr Ear (Smouc Mastoid Bandaoe). 



BANDAOE8 AND BANDAOINO 25! 

fig. 1 28 both ears are treated. In the first illustration a fixing turn of the 
bandage is first applied round the head, it is then carried beneath the 
occiput at the back and brought round below the dressing over the ear. 
fairly low on the neck, as indicated by 2. This turn is carried up over the 
opposite side of the head. Subsequent turns are taken in the same direction 
as in 3, 4, 5 and 6; and finally a circular turn — 7 — is taken round the head. 
If the saJfety pin is carefully placed it can be us^ to secure all turns of the 
bandage where these cross at the side of the head (see fig. 128). 



In fig. 128, where both ears are covered as in the application of a 
double mastoid bandage the bandage may be commenced from either 
side. In the illustration given the bandage is carried from right to left. A 
circular turn round the head fixes the tail of the bandage; it is then carried 
down on one side, round the back of the occiput and up on the other side, 
being turned up on one side and down on the other to get the neat effect 
shown where me margins of the bandage converge towards the outer 
angle of the eye. 

A bandage to support the jaw (see figs. 130 and 131 ) may be applied 
by means of a four- tailed bandage, or a roller may be employed. In the 
latter case a looped bandage is applied — three turns are made — the fast 
turn, starting on the top of the head — ^indicated by an arrow — is brought 
down one side of the face, up on the other, and then taken obliquely 
across the head (see 2), below the occiput, in front of the chin (see 3), 


» i-:.. 

Fio. 129 . — ^Four-taoxo Bandaok for the Jaw. 

(1) upper tails 46 iadies long, 

(a) tails 30 inches long. 





352 BANDAGES AND BANDAGING 

round below the occiput and obliquely across the opposite side of the head 
to be pinned or stitched; the bandage finishes where it started at the point 
indicated by an arrow (see fig. 131). 



Fio. 130 . — Four-Taiij5D Jaw Bandage Appued. 

When a four-tailed bandage is used to support the jaw, a piece of material 
3J inches wide is chosen, cut as shown in fig 129. The wide part is placed 
over the chin, the upper tails which are 40 inches long are taken round, 
below the ear, to the occiput where the ends are crossed and carried 
obliquely across the side of the head, to be fastened over the forehead in 
front, 'rte lower tails are carried up the side of the head and fastened on 
top, as indicated by arrow — 2. 

A bandage applied to support the arm in the case of an injured shoulder 
(fig. 132). The forearm lies across the front of the chest, a layer of wool 
being placed between the skin surfaces and a pad in the axilla of the in- 
jured side. The bandage is applied round the trunk and over the elbow 
fixing the arm to the side of the body. 

T^e first turns are round the body and over the elbow in the direction 
indicated by arrow i ; having fixed Ac arm, Ac bandage is carried across 
the back of the chest, beneaA axilla and over Ae shoulder of Ae opposite 
side as in 2, then across back of chest again, down to below elbow and up 
over the anterior asp>ect of the chest, and over Ae injured Aoulder as 
arrow 3. As many turns as required to support Ac cl^w, forearm and 
hand are employed and Ac bandage is finished in front as Aown. 

To retain a dressing in one axilla and over the front of one 
breast an application as m fig. 133 may be employed. The first turns arc 
earned round the trunk in Ae direction Aown by arrows i and 2, Ac 
third turn is taken slightly obliquely over Ac front of Ac chest, and on to 
the outer aspect of Ae arm; from here it is carried downwards round Ac 
arm and up as indicated by 3; Ais turn over breast and shoulder is re- 
peated as often as necessary to cover any Aessing on Ac upper part of 
the breast. See fig. 133. 

To retain dressings on the side of the neck a bandage as shown in 
fig- 134* *®ay be used. The tail of the bsuidage (which would ordinarily 




254 8AN0AOES AND BANDAGING 

be covered but has been left exposed to indicate its position) is indicated 
as letter A. From here the bandage is carried round the arm, in order to 
fix the end, as i . It is next taken round the opposite side of the neck and 
under axilla as 2. The next three turns are taken round the neck in the 
form of a simple ascending spiral. The 5th turn, after passing beneath the 



Fio. 133. — Bandage to Cover Dressing for Fig. 134. — Bandage to Cover a 
Breasi' and Axilla. Dressing on the Side of the Neck. 


chin, b carried up on the opposite side of the face (in front of the car), 
and down on the near side as 6 — the 7th turn is a repetition of this except 
that it lies behind the ear on the opposite side so tiiat the ear of the 
unaffected side b not covered by bandage. The 7th turn after passing 
beneath the chin is carried across the side of the head as shown in turn 8, 
and then round the head to be finbhed as X. 

To cover a dressing at the back of the neck— (see fig. 135), the 
bandage may be commenced from cither side — ^in the illustration it is 
carried from right to left. Arrow 1 indicates a circular turn round the 
head, the next turn 2 b brought obliquely across the back of the head, 
carried beneath the chin, high on the neck, and round the opposite side 
to the front of the head again. Subsequent turns arc made as indicated by 
figures and arrows. See fig. 135. 

A bandage to retain a dressing on a stump b arranged similarly to 
the well-known capeline used for the head. In illustration, fig. 136, the 
first turn b taken over the end of the stump as indicated by i ; subsequently 
the bandage is carried backwards and forwards as indicated by 2 and 3, 
and 4 and 5, until the stump u covered; drculau' turns aure then carri^ 




BANOAOBS AMD BANDAOlNO 255 

up the limb for as far as necessary in order to prevent the bandage from 
slipping down. In a very restless patient it would be advisable to continue 
the ba^age over the hip joint as an ascending spica for one or two turns. 



Fio. 135 . — Bandaob to Cover Dressino on Back of Neck. 



Fio. jjB.— -Bandaoe «) Retain a Dntssmo on a Stomp. 



BANDAGES AND BANDAGING 


256 

THE TRIANGULAR BANDAGE 

The triangular bandage was first used by Professor Esmarch. It is 
readily improvised from a triangular scarf or piece of material. Un- 
bleached calico is frequently used as it is cheap and strong. The bandage 
may be used whole as the large arm sling, or it may be folded broad to form 
the small arm sling, and folded narrow to form the craoat bandage. In one 
form or another the triangular bandage cab be applied to practically every 


Apex 



part of the body. The unfolded bandage is employed where it is desired 
to cover a fairly large area. The bandage fold^ broad is used to retain 
dressing in position and apply splints to different parts, and the narrow 
bandage or cravat sling is employed principally to tie splints together, to 
act as a fixing point for a wider bandage and as the cravat sling shown in 
fig. 1 39. Some examples of the use of the triangular bandage are appended. 

Large arm sling (to support elbow). The unfolded bandage is placed 
over the front of the chest as in fig. 137; A, with the apex towaim the 
injured side. The forearm is flexed and placed in front dS the bandage 



THE TRIANOULAR BANDAGE 257 

which is then taken up over it. The two ends are tied in a reef knot and the 
apex is brought round and pinned to the bandage in front of the arm as in B. 

The forearm must be supported and the hand as far as the knuckles. 
The hand must always be placed at a level slightly higher than the elbow. 



Small arm sling. The triangular bandage folded broad is used for 
this, it is applied as shown in fig. 1 38. It may be tied at either side of the 
neck, but the support obtained is firmer when tied on the unaffected side 
as shown. 



Fio. 138. — SuALi. Arm Suno to Support Forearm. 

Cravat sling. For this, the triangular bandage folded narrow is used, 
rhe band^pe is placed round the neck with one long end crossed over 





258 BANDAGES AND BANDAGING 

one short end as shown in A. The elbow is flexed. The long end of the 
bandage is taken up in iront of the wrist and passed behind the two 
folds as they lie crossed on the chest, this brin^ the two ends opposite 
each other as in B. The two ends are then tied in a reef knot well down 
on to the wrist so that the patient is unable to withdraw his hand from 
the cuff. The completed handle as shown in C is similar to the collar 
and cuff retention brace; it is used to support the elbow in flexion. 

Sling for support of elbow. The unfolded triangular bandage is 
placed in front of the chest, one end being taken up over the injured side 
and the apex lying towards the unaffected side. The end that is hanging 
down is then taken up over the forearm which lies across the chest with 
the fingers directed towards the opposite clavicle. The ends are tied at the 
side of the neck as in B. The apex of the bandage is then carried up to the 
shoulder of the injured side and when pinned to the bandage in front of the 
clavicle of this side as in C, it will be found that the whole forearm is 
supported from the elbow to the ulnar border of the hand and fingers. 



The St. John’s sling (to support shoulder). This is used when the 
shoulder is injured and painful, properly applied it gives good support. 



Fio. 141 . — ^Lakoe Am* Suno tor Support of Elbow. 



THB TRtANOULAk BAND AOS 259 

The arm of the injured side is flexed and an unfolded triangular bandage 
is placed in front of it as in A. The elbow is supported and the base of the 
bandage is tucked beneath the forearm (between it and the front of the 
body), the free end of the bandage being carried across the back to meet 
the other end on the opposite shoulder. These ends are tied. The apex 
which lies beside the injured elbow may be placed and pinned in front of 
or behind the elbow, or turned in and pinned as shown m the illustration. 

Triangular bandage for breast. By cutting an armhole as shown in 
fig. 142, and making small gussets as indicated by inverted arrows along 
the base of the bandage, a triangular bandage can be used to retain a 



I'lG. 14a. — Modified Triangular Bandage Applied to Retain Dressing on the Breast. 


dressing on the breast in such cases as those who after radical mastectomy 
may be undergoing radium treatment and require dressings to be com- 
fortably retained during the period of reaction. The bandage is pinned 
on the shoulder. 


Barrel jaw bandage. 



I'll-.. 143 .-- -Tub Folded Band- 
AGi' IS Taken prom Beneath 
the Chin and the Ends ark 
Crossed on the Top op the 
Head as Shown. 



Fio. 144. The Ends are Opened by the 
Fingers as Shown. One Passes in Front 
of the Forehead and the Other Behind 
the Occiput. 


26 o bandages and bandaging 

Barrel jaw bandage. The barrel bandage may be applied by means 
of a strip of bandage material or by using a triangular bandage folded 
narrow, see below. Sec also p. 259, figs. 143-144. 



Fig. 145. — Traction is 
Made on the Ends 
UNTIL THE Jaw is Firm- 
ly AND Comfortably 
Held by the Bandage, 
THE Ends are then 
Tied on Top of the 
Head. 



Fig. 146. — Side View of 
the Completed Barrel 
Bandage which is Easy 
TO Apply and Com- 
fortable to Wear. 



Section 2 


The Feeding of Adult Patients and Infants 
and Elementary Dietetics 


Chapter 16 

Food and Feeding of Adult Patients 

Classification of foods — The use of proteins^ carbohydrates and fats — The value 
of water to the body — The use of salts y vegetables and fruits y milk and eggs — The 
preparation of milk for invalid feeding — Serving food to patients — The administra- 

tion of fluid diet 

T hat she may help in the proper feeding of a patient, it is necessary 
for a nurse to have some knowledge of the different classes of food 
and of their value to the body. The combustion of food in the body 
provides heat and energy and makes possible the growth of new tissue 
and repair of waste, and provides, moreover, the material which enables 
the various systems of the body to perform their different functions. 

For a diet to be adequate it must contain proteins, fats and carbohy- 
drates, water, salts and vitamins; and for it to be well balanced it must 
contain the first three in moderately definite proportions. The amount 
of protein and fat is small compared with the quantity of carbohydrate 
provided as suggested by most physiologists. The following table is an 
average one: 

Proteins 80-100 grammes 320 G. 

Fats 80-100 „ 720 G. 

Garbohydrates 500- „ 2000 C. 

The Galoric is the unit of heat, each Galoric represents the amount of 
heat required to increase the temperature of i litre of water i® G. 

Foods may be classified as organiCy such as those obtained from animal 
and vegetable sources — proteins, fats and carbohydrates, each one con- 
taining different proportions of carbon, hydrogen and oxygen; and 
inorganic foods such as water and salts. 

Protein is also described as nitrogenous food, as in addition to con- 
taining carbon, hydrogen and oxygen it contains nitrogen and also 
phosphorus and sulphur. The nitrogen in protein is composed of a series 
of amino^acids; some proteins contain all the important ones, and are 
clcscribai as first class or examples are miUc and meat; others 

contain fewer and arc second class or incomplete proteins— examples of these 
include vegetable proteins, particularly those contained in peas, beans and 
lentils. This proton is called Ugumin and these substances arc described as 
legumes, or pulses. 

a6i 



262 FEEDING ADULT PATIENTS 

Reference to the table, given below, will show that protein food contains 
4-1 Calories per gramme, but protein is not generally used for the pro- 
duction of heat and energy, and the amount contained in a well-balanced 
diet, is sufficient to repair the waste of the body tissue only. In 
certain diets, where carbohydrate and fat have to be restricted, protein is 
used in larger quantities in order to provide a source of heat and energy 
but, generally speaking, the loss of energy which is caused through the 
excretion of the waste products of protein is so considerable that it is 
commonly considered inadvisable to use protein for the production of heat. 
Protein moreover is more expensive than carbohydrate. It is estimated 
that: 

I gramme of protein contains . . 4-1 C. 

1 „ „ fat „ . . 9 3 C. 

I „ „ carbohydrate „ . . 4*1 C. 

The ^ount of protein contained in various diets will be seen in those 
described as high and low protein diets in the table given on p. 279. A 
high protein diet contains about 120 grammes and a low protein diet 
50 grammes. 

Lean beef and mutton contain about 10 per cent, protein. Fish is one 
of the most easily digested protein foods, and poultry comes next in regard 
to ease of digestion and assimilation, chicken being best because it is 
tender; duck or goose is not suitable for invalid diet as the flesh contains 
a good deal of fat. 

Internals. The value of the internal organs of animals varies in useful- 
ness, but suitetbread (the pancreas) and thymus arc easily digested foods. 
Tripe is very easily digested provided it is boiled for a long time. Tongue 
is usually tender and can be used instead of lean meat as it has the same 
food value. Hearty kidney and liver arc very dense in structure, and this ren- 
ders them tough and difficult to digest; liver contains glycogen and cannot 
be used as meat when carbohydrate foods are restricted, but it is a par- 
ticularly valuable article of diet in the treatment of severe anaemia. 

The chief end-product of the internals of animals is uric acid, which is 
excreted in the urine — internals arc, therefore, contraindicated in the 
treatment of gout and chronic rheumatism, as well as in fibrositis and 
other conditions where excess uric acid is excreted. 

Carbohydrates. These include starches and sugsirs, which contain 
carbon, hydrogen and oxygen, and are mainly of vegetable origin and 
classified into three groups according to their complexity or simplicity: 

Polysaccharides — ^animal starch, e.g. dextrose and glycogen. 

Disaccharidcs — cane sugar, beet and milk sugar. 

Monosaccharides — ^Thesc are the simplest ones into which all others 
must be reduced before they can be made use of in the body — 
examples of these arc glucose or dextrose, and fructose. 

Carboh^rate foods provide heat and energy, and arc reduced to glucose 
in the tissues and stored in the muscles and liver as glycogen; a great 
increase in the intake of carbohydrate would lead to storage of fat in the 
tissues. Starchy foods are also described as farinaceous. The main ones arc 
true cereals, others are starch. Cereals are obtained from the grain of 

f flants and the seeds of grasses, and include wheat grain, such as flour 
rom which we make br^ul; semolina and macaroni arc preparations of 



FEEDING ADULT PATIENTS 363 

wheat. Oat grain is supplied firom oatmeal, and barley is used as pearl 
barley in thickening soups and broths, as barley water for invalid feeding, 
and is a source from which malt is obtained in brewing beer. Rice con- 
tains large quantities of starch and is a favourite milk pudding. Tapioca 
and arrowroot arc preparations of starch obtained from the roots of plants. 

Fats. Fats, composed of fatty acid and glycerine, arc mainly derived 
from animal sources, although some are vegetable. Fat is a fuel food but it 
is v^ difficult for the body to digest and assimilate it. Excess is stored as 
fat in the subcutaneous tissue around the kidneys and heart, and other 
internal organs, and in the interstices of muscle tissue. The amount of fat 
varies in an average diet from 80 to 100 grammes, and if, for example, a 
diet contains 100 grammes of fat and protein, 500-600 grammes of car- 
bohydrate will be added to this; the proportion of fat to carbohydrate is 
therefore i to 5 or 6, but fat is sometimes added in considerable quantities 
in the administration of special diets and the treatment of diseased condi- 
tions. 

For example — ^whenever a high Caloric diet is required, fat is the article 
of diet added, in which case the choice of fats should be the more easily 
assimilated ones, such as milk fat, which is administered in wasting 
diseases such as pulmonary tuberculosis where as much fat as the patient 
can comfortably be persuaded to take is added to the diet. 

Fat is added in very considerable quantities when a ketogenic diet is 
given; this diet is so named because the fat content is pushed far enough to 
produce a condition of ketosis. It was first utilized in America in the 
palliative treatment of cases of epilepsy, as it had been observed that per- 
sons suffering from epilejisy who had accidentally developed ketosis were 
free from fits during this period. It has more recently been adopted in this 
country in order to produce a highly acid urine in the treatment of bacil- 
luria due to the presence of bacillus coli. In the condition of ketosis the 
alkalinity of the blood is slightly decreased and the urine becomes highly 
acid. 

Water. Water is essential to the tissues of the body, about three to four 
pints being supplied daily with an average diet — probably half this 
quantity is taken in as drinks, water, lemonade, tea, &c., and the other 
half is contained in the food eaten. For example, large quantities of water 
arc contained in all food, and some fruits and vegetables contain over 90 
per cent, of water. The bodily excretions eliminate 4 to 5 pints a day — 
from 40 to 50 ounces as urine, perhaps i| to 2 pints as sweat, in addition to 
moisture present in the expired air which is saturated with water vapour, 
and the water present in faeces. It is an interesting fact that water does 
not undergo any change in its passt^e through the body. 

Water is required for the function^ activity of all the organs, and for 
the carryiiw out of all chemical processes in the body upon which life 
depends. It is not possible to live many days without water. It helps in the 
regulation of the body temperature, particularly as the loss of heat, which 
forms part of thb mechanism, is made possible by the evaporation of 
moisture from the surface of the body. By means of water the chemical 
agents arc conveyed to and from the different parts of the body. 

Water serves to dilute the substances taken in as food. These cannot be 
swallowed until they are comfortably moist; they cannot be acted upon 
by the different enzymes, responsible ftw changing them chemicsdly. 



264 FEEDING ADULT PATIENTS 

until they have been dissolved. Water is also essential for diluting the 
waste products of the body, and any poisonous products which may get 
into the body, and by so diluting them to render it possible for such waste 
products to be eliminated by the kidneys. It is in order ftirther to dilute 
these products that water is liberally provided in the treatment of most 
febrile conditions when metabolism is rapid and the breakdown of tissue 
greater than normal. 

The administration of increased fluid volume is indicated in all conditions of 
toxaemia; in most febrile conditions and when the rate of metabolism is 
increased; and where the administration of fluid acting as a diuretic will 
increase the urinary output; many cases of constipation may be relieved 
simply by the addition of water to the diet. In nursing sick patients many 
symptoms of discomfort may be obviated and others relieved, particularly 
those associated with a dirty mouth, thirst, constipation, insomnia, rest- 
lessness and delirium, by the administration of copious drinks of water 
and other watery drinks at regular frequent intervals. 

Restriction of fluid. Fluid is restricted in conditions of oedema such as 
occurs in advanced cardiac and renal disease; in cases of high blood pres- 
sure accompanied by arteriosclerosis in which rupture of an artery may 
occur, and give rise perhaps to the condition of cerebral haemorrhage. 
In these instances fluid is restricted to i-i | pints a day. In the administra- 
tion of a kctogenic diet, mentioned on p. 289, fluid is very carefully 
restricted, as little as from 8 to 15 ounces per day being allowed. 

In the administration of diets in which fluid b restricted to a given 
amount, it is necessary' to take into consideration the actual fluid value of 
certain foods, particularly fruits, as few example plums, apples and oranges, 
which contain almost their total weight of water, so that a large plum 
may be providing an ounce or two of fluid, and an apple three ounces. 

In dilatation of the stomach, when the fluid accumulates in the distended 
organ, the amount given is carefully considered; it may be restricted, or a 
normal amount of fluid may be given, though this must be administered 
in small quantities at a time. In the dietetic treatment of obesity, the fluid 
intake is also graduated. In some persons a considerable amount of tiieir 
excess in weight is due to fluid, and with these it is sometimes advisable to 
restrict fluids at meals, allowing them to be taken only between meals. 

Salts and condiments. Salt is used to flavour food, but in addition it 
is essential if osmosis is to take place, since its presence regulates the con- 
centration of fluid in the tissues. The presence of salt is necessary in the 
stomach for the secretion of hydrochloric acid. Salt is restricted in cases of 
oedema, as when fluid is retained in the tissues the administration of salt 
would result in a greater collection. It is also restricted in nephrosis and in 
all conditions where the function of the kidneys is disabled, because salt is 
eliminated by the kidneys, and its restriction therefore lessens the neces- 
sary work of these organs. Other common condiments include pepper, 
mustard, vinegar and spices, which are chiefly used for flavouring. 

Vitamins are essential food factors which have definite physiological 
and also therapeutic value. A balanced diet must contain suflldent 
vitamins. These substances are classified into: 

Water-soluble vitamins — ^ — B and C. 

Fat-soluble vitamins — A, D, E and K. 



FEEDING ADULT PATIENTS 265 

Information as to the sources and special values of the different vitamins 
is contained in a chart in Appendix 2, on page 804, and some information 
on this subject is also inouded in the note on deficiency diseases on 
page 289. 

Vitamin therapy is possible today because of the many potent preparations 
of vitamins available such as halibut and cod-liver oil, rose-hip syrup and 
black-currant pur6c. Synthetic preparations of some of the vitamins are 
also available, notably that of vitamin C or ascorbic acid. 

The protective foods. The foods described as protective contain, the 
essential vitamins, fats, first class protein, and salts including iron, phos- 
phorus and calcium. In order to maintain good health definite amounts of 
these substances must be provided, daily, in the meals taken. The amounts 
vary according to the age of the individual and the type of work done. 
Children, women during pregnancy and whilst feeding their infants require 
more than other individuals. Protective foods are needed in larger quantities 
in the treatment of deficiency diseases (see p. 289) . 

Vegetables and fruits have very definite value as articles of diet. 
Green vegetables^ such as cabbage and spinach, contain some valuable 
mineral salts, such as phosphorus and potash, and in spinach iron is 
present in considerable quantities. When cooked, most of the salts con- 
tained in green vegetables pass into the water and it is for this reason that 
good coolu use vegetable water for soup stock, &c., and whenever possible 
cook vegetables in very small quantities of liquid. 

In addition, vegetables provide considerable bulk in the intestine, and 
are therefore valuable in the treatment of that form of constipation which 
is due to sluggish peristalsis, the bulk helping to stimulate the activity of 
the intestine. Vegetables would, however, be contraindicated in constipa- 
tion due to spasm, as in these cases peristalsis is irritated and occurs 
irregularly, so that for this type of constipation a bland non-irritating diet 
is desirable. When eaten uncooked, green vegetables are valuable for 
their vitamin C content. 

Root vegetables such as potatoes, carrots, parsnips, turnips, Jerusalem 
artichokes and beetroot contain starch in varying quantities. Potatoes 
provide the most prolific source of starch, and because of their starch 
content these vegetables have to be specially considered in the administra- 
tion of a diet of low carbohydrate value, as in the treatment of diabetes 
and in obesity. 

A potato is a good source of vitamin C which is contained immediately 
beneath the skin of it. It is for this reason that {x>tato cream is advocated 
in the treatment of scurvy; this is made by carefully collecting the potato 
beneath the skin of one boiled in its jacket and mixing it to a creamy 
consistence with a little cool milk. 

Frtdts contain large quantities of water, very small quantities of carbohy- 
drate and some cellulose, their natural sweetness being due to fruit sugar. 
Banana contains more carbohydrate ffian most other fruits and, in addi- 
tion, a little protdn. Some ^its contain more cellulose than others, 
examples of these ate apples and lemons which are particularly useful as 
laxatives in Ae treatment of constipation. Lemons, oranges, grapefiuit 
and tconatoes contain citric acid. Grapes contain tartaric acid. It is 
because of their acids that these foods are frequently made into drinks 
and used as mUd diuretia. 



266 FBEDINO ADULT PATIENTS 

Milk and eggs are so largely employed in the feeding of invalids that 
a note on their utility may be useful to nurses. The value of milk as invalid 
food lies in the fact that in addition to the presence in it of all the foods 
mentioned in a well-balanced diet, these are present in the forms most 
easily assimilated by the body, and quite natmally so, since milk is in- 
tended for the young of man and animals. Each milk is specially suited 
to the young of the animal for which it is intended, and it is for this reason 
that cow’s milk requires special treatment before it can be rendered suit- 
able for the yoimg baby. 

The protein of cow’s milk consists largely of caseinogen, which forms a 
heavy curd. For this reason it is citrat^ or diluted, and in some cases 
peptonized, when used for invalid feeding; and humanized when em- 
ployed for baby feeding. The carbohydrate of milk being lactose is readily 
used by the body. Milk fat is almost an emulsion — it is separated in tiny 
globules, which being lighter than the fluid rise to the surface as cream. 
The mineral salts need^ by the body are contained in milk, with the 
exception that cow’s milk contains insufficient iron for baby bcxly build- 
ing. The vitamin content in milk depends upon the feeding of the cows; 
pasture-fed cattle yield milk rich in vitamins A and D, and some B and C 
arc present but the two latter are rapidly destroyed when the milk is 
heated. 

The uses of milk. Milk as a food makes the least demand on the digestive 
and excretory organs, and there are many ways of modifying it to increase 
its usefulness in invalid feeding. Most febrile cases can be given diluted 
milk , as a rule 5 ounces of fluid are given to such cases every 2 hours. The 
protein of mUk is one most easily dealt with, and it provides the least 
possible amount of waste matter for elimination by the kidneys. Milk and 
water can therefore be given in most cases of acute nephritis and acute 
rheumatic fever. 

Because of its nourishing properties milk is an excellent addition to the 
diet where the Calorie v^ue is required to be high. An ounce of milk 
provides 20 Calories, so that the addition of one or two pints of milk to the 
diet is an excellent means of adding some 400-800 Calories in the treat- 
ment, for example, of patients who are convalescent after certain wasting 
diseases and acute illnesses. 

THE PREPARATION OF MILK FOR INVALID FEEDING 

Most of the methods used aim at reducing the density of the curd. The 
rennin present in the normal stomach cui^es milk, but by diluting the 
milk with barley water or soda water, half and half, or in the proportions 
two-thirds of milk to one-third of water, or cilrating the milk by the addi- 
tion of 2-4 grains of potassium citrate to the ounce, the amount of this 
curd can be reduced. 

Peptonizing is carried out whenever further action upon the curd is 
advisable, and is a process by means of which the protem in the milk is 
predigested. A Fairchild’s peptonizing powder is ^ded to 5 ounces of 
water and i pint of milk, and the mixture is then heated to 105° F., and 
kept at that temperature for 10-15 nainutes. It is then either rapidly 
cooled by placing it on ice, or heatedf to 150° F. in order to stop the action 
of the peptonizing agent. 

Separation of the curd of milk results in the prq>aration of wh^. Whey 



PREPARATION OF MILK FOR INVALID FEEDING 267 

contains fats, sugar, salts and the vitamins, in fact everything except the 
protein which is contained in the ciu”d which has been separated. Whey is 
prepared by heating milk to 100° F. and adding one drachm of rennet 
(a preparation of rennin) to each pint, letting it stand in a cool place until 
set, and then stirring it with a fork to break up and separate the curd and 
draining the whey off through muslin. Lemon wh^ can be made by adding 
half an ounce of strained lemon juice to a pint of milk; white wine whey is 
made by adding a gill (4 ounces) of white sherry to a pint of milk. In both 
cases the curd is separated and the whey drained off through muslin. 

Skimmed milk is used when the greater part of the fat is required to be 
removed, as in the treatment of come cases of jaundice where extreme 
nausea is a feature of the symptoms. 

Lactic acid milk is made by adding 45 minims of lactic acid to a pint of 
milk and stirring it in very slowly drop by drop, in order to avoid curdling 
the milk. It is used in the treatment of marasmus babies, particularly 
when this condition is due to diarrhoea and vomiting. 

Junket can be made by adding a drachm of rennet to a pint of milk as 
described in the preparation of whey, but it is served only when the milk 
is set. It may be coloured and flavoured. Milk jelly is prepared by adding 
a quarter of an ounce of leaf gelatine to each hjilf-pint 01 milk. The gela- 
tine is dissolved in a small quantity of milk and the mixture allowed to set 
in a cool place. Milk can be varied by the making of milk tea, coffee and 
bovril, milk being used instead of water in the preparation of these 
beverages. 

Eggs. The Calorie value of a hen’s egg weighing 2 ounces is 80. Eggs 
arc very valuable as an article of diet b«ause they contain a quantity of 
meful protein — albumin — ^in the white of the egg. This is coagulated by 
heating, and is therefore most easily digested uncooked and may be given 
as albumin water. This is made by cutting the white of an egg in order to 
break up the membrane and mixing it with 5 to i o ounces of cold water. 
It may be mixed with the ssime quantity of lemonade instead. Albuminized 
drinks should be strained through muslin before they are served. 

Egg drinks. Egg flip may be made with the whole egg, or only the white 
used. In both cases the white should be whipjwd until it is a stiff froth, 
and either milk, a mixture of milk and cream, cream and sherry, or milk 
and brandy may be added. The drink should be flavoured to taste. 

The yolk of an egg contains a fairly large amotmt of fat which provides 
vitamins A and D, but the presence of lecithin and cholestrin renders it 
indigestible, and egg yolk as an article of diet is contraindicated in the 
treatment of conditions of the liver and gallbladder, in many cases of 
obesity and in all persons subject to biliousness. 


POINTS TO BE CONSIDERED IN SERVING FOOD TO 

PATIENTS 

Having considered the types of food available and the need of these, the 
conditions in which special types of food are indicated in some cases and 
contraindicated in others, the nurse should next realize that food must be 
properly cooked in order to render it digestible, and, although this may 
not be her duty, it is nevertheless within her province to see that the food 
is invitingly served. It is usually considered inadvisable to discuss food 



268 FEEDING ADULT PATIENTS 

with patients except in so far as to consult their wishes and likes and dis- 
likes with regard to it, in a purely general way, as soon as they have 
setded down in hospit^. 

The value of any one meal to a given person, whether healthy or ill, 
may be assisted or retarded by the state of mind in which it is approached. 
To have to face a meal after fadgue, after hurry, anxiety and worry will 
fail to give the maximum result. On .the other hand, this will be best 
obtained by a peaceful, contented, happy state of mind contributed to by 
cheerful surroundings and if possible by congenial company. Care should 
be taken to avoid monotony in diet and, although this may not be alto- 
gether within the scope of a probationer in hospital, it is possible in many 
instances to make little alterations. The night nurse, for example, might 
vary the arrangements for breakfast, so that a patient on full diet is not 
given the same meal each day. Again, with regard to the evening meal, 
in many hospitals it is possible for the nui-se to plan small dishes of jelly, 
fruit salad, &c., and so to do much to add to the variety of the diet and 
give pleasure to her patients. If mince or shepherd’s pie is served for 
supper it can be made more inviting, appetizing and palatable by the 
simple addition of small crisp pieces of toast. In the case of a patient on 
milk diet, small variations can be made — a little fruit juice and sugar 
will serve to make milk pudding more appetizing to some. 

Punctuality in serving meals is important, and absolute regularity must 
be obseived in the administration of fluid feedings and special diets. Most 
of these arc given two-hourly or four-hourly, and unless one has been a 
patient on a special diet it is impossible to visualize the (possible) pleasure 
the thought of the next meal, however small, will give. The patient care- 
fully observes the time it is due, he watches his nurse leave the ward for the 
kitchen and thinks he will get his diet next: if it does not come, he is 
disappointed, and perhaps by the time it arrives the pleasurable anticipa- 
tion has given place to painful, irritable anxiety — especially in the case of 
men — in which case the digestion of the meal may be seriously impaired. 
Patients with poor appetites and a distaste for food have to be gently 
persuaded to take it, yet they should never be forced. A little change of 
dish, an alternative diet if possible, or even taking the patient’s plate 
away and rearranging the fo^ upon it, may secure the eating of the food. 

Preparation of the patient. The ward should be quiet and orderly, 
all unpleasant sights should be removed, any very seriously ill patients 
should have screens placed roimd their beds, no visitors should be per- 
mitted, in order that the patients may eat undisturbed and unobserved. 
The nurses should have their sleeves down and cuffs on preparatory to 
serving a meal and, however busy they may have been during the morn- 
ing or evening, they should now concentrate on being happily engaged 
in the work of the moment-— which is serving the patienta meal. 

The preparation of the patient for his food is of the utmost importance, 
and he should be comfortably supported by pillows, his shoulders being 
protected from chill; if necessary a knee pillow should be inserted in order 
to prevent painful stretching of the hamstring muscles as the patient sits 
up or leans forward. The bedtable should be placed where it will be 
comfortable; if only a tray is used some provision must be made for 
adequate support in a place the patient can conveniently reach (see 
preparadbn trays, bdow). The table napkin or diet cloth should be 



POINTS TO BE CONSIDERED 26g 

placed within reach of the patient, or if he is helpless it should be arranged 
for him. As far as possible a meal should not be given after a distresnng 
treatment or pain^l dressing. 

Preparation of tray and delivery at bedside. Trays must be daintily 
prepared and have clean traycloths, if these are used. The tray should be 
complete with all necessary articles placed in the most convenient position 
for tne patient to reach, such as a drink, condiments, &c. The glass or cup 
containing the driidt should never be so full that it can be spilled or is 
capable of splashing over as the patient makes a slight movement in bed. 
Small helpings should always be given and ail food placed very neatly on 
the plate; the patient’s wishes ought to be consulted as to whether he likes 
gravy with meat, sauce with fish and so on. Cold food should be served on 
a cold plate, and hot food on a really hot plate. Only one course is served 
at a time, and the soiled articles from the previous course should be re- 
moved before it is delivered. Hot water plates ought to be provided when- 
ever there is a long distance to cover between kitchen and bedside and in 
cold weather and whenever patients are being nursed in the open air. 
The tray should be removed the moment the patient has finished, so that 
he can be made comfortable in bed and rest, and so fulfil the requirements 
necessary for perfect digestion of the meal. 

Whenever a patient requires help with his food this must be generously given, 
without his feeling that he is being hurried in the slightest. If hot food 
requires to be cut up this should be done in the kitchen on a hot plate if 
possible, and not at the bedside where it will be getting cold during the 
process. When a helpless patient requires to be entirely fed witli food and 
drink a diet cloth or table napkin should be tucked underneath his chin, 
over his personal clothing and bedclothes in case of accident. In giving a 
drink to a very helpless patient the head should be raised by the nuree 
placing her arm underneatli the patient’s pillow and elevating his head 
and shoulders; the drink is then put to the patient’s lips and sm^l mouth- 
fuls given at a time. A patient can stem the flow from a feeder with a spout 
by putting his tongue against the opening in it; but this should not be 
necessary as if the nurse watches her patient carefully she will note when 
he has enough fluid in his mouth to be comfortable, and she will accord- 
ingly lower the utensil whilst he swallows. A patient should be allowed 
time to breathe between mouthfuls, as he cannot both breathe and swal- 
low at the same time. Longer rest should be given at intervals in all cases, 
and most particularly when swallowing is difficult or painful and whenever 
dyspnoea is present. 

Food chart. When a food chart is kept it is used to indicate the amount 
of food taken. A nurse should always report on the amount of food a 
patient has eaten. Whenever a tray is taken away from a patient’s bedside 
the amount of food left should be observed and reported to the head nurse 
or ward sister. 

Waste food. In large institutions any waste food is sold as pigwash, but 
pig owners object to the presence of eggshells, tealeaves or fruit skins or 
stones, and other odd articles which sometimes find their way into this 
receptacle, including screwed up bits of paper, empty tins, &c. It is part 
of the economy of the hospital to sdl waste food as pigwash and it is, 
therefore, most definitely the duty every nurse and probationer to see 



270 PKEDINO ADULT PATIENTS 

that the quaility offered for sale is of a good order. In cases of infection all 
waste food has to be burnt. In some large hc^pitals for the treatment of 
pulmonary tuberculosis, waste food is sterilized and then given to pigs. 

THE ADMINISTRATION OF FLUIDS 

Patients are sometimes ordered fluids ad libitum. This does not mean 
the amount the patient wants but the gi'eatcst amount he can be per- 
suaded to take by a good nurse who has an intelligent interest in the 
patient’s welfare and knows what he ought to have. As in the adminis- 
tration of all special diets, regularity and promptness arc most important. 
In such cases it is usual for the patients to be given a drink every two hours, 
in many cases five ounces will be given at a time, water being given in 
between each nourishing drink. In addition the nurse should be on the 
look-out for opportunities to give an extra drink at any time, as for 
example when a patient wakens from a short sleep or doze, after a little 
talking or after making his bed or performing some other treatment for 
him. TTie nurse must not consider her duty done when she has placed a 
feeder of drink on the patient’s locker — she has also to see that he drinks 
it within a reasonable time. 

A patient on fluid diet should have his mouth cleaned regularly, at 
intervals of either two or four hours, and usually before a nourishing drink 
is to be given. Whenever possible after a milky feeding has been adminis- 
tered a small drink of water should be given in order to prevent the milk 
from clinging to the patient’s mouth as milk is a food which quickly 
decomposes, and becomes a very ready medium for the growth of 
organisms and so results in the formation ofsordes and crusts on the teeth. 
Milk should always be given very slowly, as it is sometimes quite difficult 
for patients to digest even diluted milk. 

For a patient on a nourishing fluid diet, a definite plan ought to be fol- 
lowed and, taking a case of lobar pneumonia on such a diet, the following 
table is usrful, and the plan adopted is to give the patient 2 pints of milk 
and 1 pint of meat broth, in addition to 3 pints of water or other simple 
drink. In the following arrangement care should be taken to space the 
more nourishing articles of diet evenly throughout the day, and yet at the 
same lime to avoid monotony: 

6 a.m. Milk 5 ounces, water 2 ounces, flavoured with tea. (The 
patient looks upon this as an early morning cup of tea.) 

8 a.m. Milk 5 ounces, water 2 ounces, flavoured with Horlick’s or 
ovaltine. 

10 a.m. Chicken broth, 7 ounces. 

12 noon. Milk 5 ounces, and water 2 ounces, and if eggs are permitted 
a beaten egg is added to this, and it might be looked upon 
as lunch. 

2 p.m. Beef tea or light soup, 7 ounces. 

4 p.m. Milk 5 ounces, water 2 ounces, flavomed with tea or coffee 
(the :fftemoon drink). 

6 p.m. Chicken broth, 7 ounces^ 

8 p.m. Milk 5 ounces, and water 2 ounces, and if an egg is permitted 
the second egg might be given here; if not, the feedii^ might 
be flavoured with ovaltine or Horlick’s or, if Benger’s food 



THE ADMINISTRATION OF FLUIDS 27 I 

is permitted, this could be given and regarded as the 
evening meal. 

lo p,m. If the patient is not asleep, milk 5 ounces and water 2 
ounces can be given. 

By this arrangement, the patient has received 35 ounces of milk, and a 
pint of broth. The night nurse will give the patient probably five to ten 
ounces of milk during the night. 

Water, lemonade or barley water should be near at hand and the nurse 
should make a rule of giving the patient three to four oimces of one or 
other of these drinks at the intervals between the feedings — say at 7, 9 and 
1 1 a.m., and i, 3 and 5 p.m., and $0 on. This will give eight drinks, total- 
ling about 30 ounces, which is the minimum the patient should receive. 
By judicious management double this quantity can easily be given. Some 
care ought to be taken in order to avoid following a drink of milk by 
lemonade. Barley water or water should be employed after milk, and 
lemonade given after soup. 

It is sometimes difficult for patients to swallow fluids and easier for 
them to take soft solids; in these cases some of the foods can be made into a 
cream or jellied. Any fluid may be jellied by adding a quarter of an ounce 
of leaf gelatine to every half pint of liquid, and in this way lemonade, tea, 
bovril, milk, beef tea, &c., can be given in the form of jelly. This method 
is particularly useful in cases of palatal paralysis which may complicate 
diphtheria, when the soft palate does not rise to close the posterior nares 
during the act of swallowing, and fluid is regurgitated down the nose. 
Most fluids can be frozen, and then when almost solid briskly whipped to 
the consistency of thick cream — given in this way they are comforting and 
soothing to patients with very sore throats and are particularly useful for 
children after tonsillectomy has been performed. 


BALANCE OF FLUID IN THE BODY 

The amount of water retained in the body is very carefully regulated 
and balanced by a most interesting controlling mechanism. In some con- 
ditions, when fluid is lost in large quantities by diarrhoea, vomiting or 
bleeding, the balance is upset, and the patient becomes what is called 
dehydrated. He looks like a shrivelled le^if, his skin is crinkled, his eyes are 
deeply sunken and his abdomen is boat-shaped. 

Dehydration also occurs when the vital reflex centres are depressed or dis- 
organized as in grave states of septicaemia and toxaemia, in conditions of 
shock, collapse and prostration, and in some conditions of chemical toxae- 
mia. In these circumstances the need of increased fluid intake is manifest, 
but at the same time the condition of the patient may be so low and so 
lacking in vitality that any fluid given by mouth will lie in a pool in the 
stomach, or if given by rectum will lie in the colon and not be absorbed, 
and therefore cannot reach the circulating fluids and so will not relieve 
the grave condition from which the patient is suffering. It is in such cases 
as these that the administration of fluid by the more direct routes such as 
the intravenous, subcutaneous and intrapcritoneal methods is so important. 

Retention of fluid is the other extreme. It occurs in certain types of 
nepluitis owing to the fall in the blood-plasma protein due to massive 
albuminuria. When the protein content of plasma falls below 4 per cent., 



272 FEEDING ADULT PATIENTS 

the fluid cannot be attracted back again into the blood stream and oedema 
occurs. It is in order to relieve this condition that the high protein diet 
introduced by Epstein, is employed in the treatment of chronic parenchy- 
matous nephritis. 

Congestive heart failure is another condition where fluid is retained in 
the tissues. In this case it is due to venous back pressure. Owing to increase 
of pressure in the veins, stagnation occurs and fluid is retained in the 
tissues. Fluid is retained in the tissues in considerable quantities before its 
presence can be detected by oedema. It increases the wdight of the patient 
and could be discovered in this way. It could also be detected by decrease 
in the urinary output which is the first sign of decompensation in congestive 
heart disease. It is important therefore that a carentl record of the intake 
of fluid and the urinary output should be kept. 

Retentim of salt in the tissues is another cause of fluid retention. The 
theory put forward is that salt retention attracts fluid in order to maintain 
the isotonic concentration. The cause of salt retention is not understood 
but it is a well-known fact that the condition is relieved by giving a salt- 
firee diet. 



Chapter 17 

The Feeding of Infants 

Compasition of milk — The preparation of milk for infant feeding — Precautions 

in feeding — Weaning an infant 

I t is very unfortunate for an infant to be deprived of its own mother’s 
milk. During the first month of a baby’s life any artificial food must be 
much dilut^, the best substitute being cow’s milk suitably modified. 
Four to five weel^ should be taken in which to reach the ideal dilution of 
equal parts of milk and water as shown in the table on p. 274; but if the 
infant is very tiny, say one or two weeks old, it may take a little longer to 
reach this ideal dilution. 

A baby needs 50 Calories per pound of body weight per day at first; 
after seven months it may be reduced to 45 Calories, and after 12 months 
to 40. He also needs 2^ ounces of fluid per day per pound of body weight. 
If therefore a tiny baby weighs 8 lb. and requires to be artificially fed, 
20 ounces of fluid should be given and the food value of the feedings ought 
to be 400 Calorics. 


Composition of milk. 

Human milk 

Cow’s milk. 

Protein 

2% (caseinogen o-6% 

lactalbumin 1.4%) 

4% (caseinogen 3-25% 
lactalbtunin 0.75%) 

Fat 

4 % 

4 % 

Sugar 

Salts 

Vitamins 

6% 

4 % 


The protein in cow’s milk is largely casein, which makes great demands 
upon the infant’s stomach as curd is formed by the action of rennin and 
hydrochloric acid on it. Lactalbumin, which forms the bulk of the protein 
of human milk, is not affected by rennin. Human milk is sterile. Cow’s 
milk, when it is obtained from a reliable dairy, can be considered safe if it 
is ^"tuberculin tested”, or “accredited”; but other cow’s milk may contain 
dirt and a large percentage of organisms, particularly coliform and tubercle 
bacilli, and must be boiled for five minutes before use as by no other means 
can it be rendered safe for infant feeding. The vitamin tontent is destroyed 
l)y boiling, but can easily be addoi to me diet — vitamin C in orange juice 
and A and D in cod-liver oil. The sugar in human milk is greater in quantity 
than in cow’s milk; the form in both milks is lactose, but in adding sugar 
when cow’s milk is humanized dextri-maltose or cane sugar is used — 
glucose is not advisable and lactose is thought to produce fermentation 
and cause sore buttocks. The fat present as cream is in fine globules in 
human milk, that of cow’s mUk being coarse and large by comparison. 

To modify fresh cow’s milk. Take equal parts of cow’s milk and 
water, which gives the following parentage — ^protein 2 per cent,, fat 2 per 
cent., sugar 2 per cent The addition of one ounce of su^ to the pint adds 

273 



274 the feeding of infants 

5 per cent., and increases the sugar content to 7 per cent.; the addition of 
one ounce of dairyman’s cream which is considered to contain 33 per cent, 
fat adds i -5 per cent, of fat to the mixture, giving a total of 3-5 per cent., 
so that the percentages now more nearly resemble that of human milk (see 
table on page 273). A solution of sodium citrate, one to two grains to the 
ounce, may be added to make the curd smaller and more digestible. Some 
authorities consider the addition of sodium citrate inadvisable and con- 
sider that if the milk is boiled for 5 minutes the protein is rendered suffi- 
ciently digestible and that the addition of sodium citrate tends to neutralize 
the norm^ acidity of the gastric secretion and cause digestive disorder. 

As the child grows older the strength of the mixture should be increased, 
so that after the fourth month the mixture will contain two parts of milk 
to one part of water, and when they reach the age of 18 months infants 
can take undiluted cow’s milk. v 

Proprietary brands of dried and condensed milk are sometimes used for infatU feed- 
ing. Dried milks represent the 1 2 per cent, solids present in cow’s milk — 
4 per cent, each offats, carbohydrates and proteins. To make a humanized 
mixture take 10 drachms of dried milk, 20 ounces of water, i ounce of 
sugar and i ounce of dairyman’s cream. 

Condensed milk is a preparation in which the water is pardy evaporated. 
A good example is Ideal milk which is fresh cow’s milk superheated and 
two-thirds of the water evaporated, nothing being added. Thus can be 
used with advantage in dealing with very sick infants. To prepare a 
modified unsweetened milk for a healthy infant take 4 ounces of the milk, 
16 ounces of water and add i ounce of sugar and i of cream. 

Calorific value. The Caloric value which should be allocated to a baby 
has already been mentioned. In order to determine whether food of the 
correct calorific value is being administered, it is useful to know the Calorie 
value of the substances used. Cow’s milk contains 20 Calories per ounce, 
and Ideal milk 49 Calories. Lactose and cane sugar arc of equal value — 

1 14 Calories per ounce; thick cream contains 1 12 Calories to the ounce; 
New Zealand cream is richer, containing 180 Calories. 

Example: a baby weighing 8 pounds requires 50 Calorics per pound — 
400 Calories. He requires 2 J ounces of fluid per pound of body weight — 
20 ounces. The milk mixture described as humanized milk contains 20 
Calorics to the ounce, 20 x 20 = 400. This is supplied as follows: 

Cow’s milk 10 ounces *= 200 Calories. 

Water 10 „ 

Dextri-maltose i ounce 108 ,, 

Cream i „ = 100 „ 

408 ,, 

Precautions in feeding. Warm the milk mixture before feeding to 
100" F, by standing it in warm water for ten minutes; too hot feedings 
destroy the mucosa of the mouth and gullet, too cool feedings give rise 
to colic and diarrhoea. A cover should be used to retain the heat during 
feeding time. It is important to see that the hole in the teat is the right 
SB* — neither too large, which would deliver the feed too rafndly, nor too 



THE EEEDINO OF INFANTS 275 

small, which would render the work df the infant too difficult. The ideal 
position for feeding a baby is on the nurse’s lap with his head resting on her 
arm, adopting, as far as possible, the position of an infant feeding at the 
breast. In holding the bottle it should be tilted so that the feeding is 
against the neck of the bottle all the time, otherwise the baby may suck 
in air. After feeding the infant should be raised to bring up wind, and then 
placed warm and dry in his cot. Tiny babies require three-hourly feedings 
and larger ones who can take more at a time may be fed four-hourly. 
Babies should be comfortable during their feeding and therefore wet and 
soiled napkins should be changed beforehand. 

Feeding bottles should be rinsed in cold water, washed and boiled after 
use, and they should be cleansed with a bottle brush and boiled and stored 
in sterile water until they are needed. Teats should be cleaned with salt, 
washed and boiled. 

A nurse ought to know whether a baby is thriving on the diet he is having, or not, 
and the chief indications of this are: 

(i) Weight, whether stationary or decreasing — ^both are unsatisfactory; 
too rapid increase in weight is also unsatisfactory — what is required is a 
regular gradual increase. An infant should double his birth weight in 5 
or 6 months, and then gain at the rate of i lb. per month during the next 
6, and weigh 28 pounds at the end of 2 years. (See accompanying weight 
chart, fig. 147) 

If the weight appears unsatisfactory, a test feed is useful in breast-fed 
infants and, in order to determine the amoimt taken, the infant is weighed 
before and after the feed in exactly the same clothing. 



Fio. 147 . — WaioHT Chart of a Normai. Irfant. 


(a) Vomiting may indicate inability to digest the feeding, in which case 
: should be ffirthcr diluted and then gradually increased again. Or vomit- 






276 THE FEEDING OF INFANTS 

ing may be merely regurgitation or posseting, which may be due to a too 
rapid taking of the feed, to too lai^e feeds, or to injudicious handling of 
the infant after feeding. 

(3) Condition of stools. An infant may have diarrhoea or constipation, and 
the latter usually indicates underfeeding, particularly when combined 
with failure to gain weight. Overfeeding usually gives rise to colicky pain, 
the child screaming and drawing up its legs immediately afler feeding; 
stools may be unduly large, or peristabis may be rapid giving rise to green 
frequent stools. The stoob should always be observed for the presence of 
undigested food — curds, fat, and any other abnormalities. 

(4) Crying usually indicates abdominal dbcomfort. It may be due to 
hunger caused by underfeeding, to abdominal distension resulting from 
overfeeding, to constipation, or to discomfort caused by being cold and 
wet or overheated by too many clothes. 

Wasting, or marasmus (athrepsia), b often brought about by injudicious 
feeding over a long period; the infant becomes wasted and dehydrated, 
with sunken eyes, dried skin, and Battened abdomen (the shape of a soup 
plate) — all symptoms which markedly demonstrate loss of body fluid. 
By the time Ae infant is in this condition he has lost all ability to take or 
to digest any food except the most dilute, and what he is able to take b 
quite insufficient for growth at a normal rate. Thb most serious condition 
accompanied by severe toxaemia and fever renders the infant acutely ill. 
In thb state he b unable to resbt even the mildest infection he may meet. 

In the treatment of such a marked degree of wasting tlie food of thb 
infant must be increased as rapidly as possible in order to supply the neces- 
sary protein for body building, and it b in such cases as these that lactic 
acid b so often used, seeing that it is of value in compensating for the low 
hydrochloric content present in the gastric juice of weakly babies. (For the 
mode of preparation of lactic acid milk, see p. 267.) 

WEANING AN INFANT 

The developing child requires some hard object to bite on at six months; 
a month or two later he may be given a crust or a piece of hard apple so 
that he can learn to masticate, but care must be taken to see that he does 
not bite off and swallow large pieces — these should be taken out of hb 
mouth. At 8-9 months of age one feeding at about midday can be sub- 
stituted by a small meal of some cooked cereal and milk, or bread and 
milk. A few days later a second meal may be added, the cereal meal being 
given at a time corresponding to breakfast and the midday meal to consist 
of mashed potato or breadcrumbs and the red CTavy of meat, followed by 
a very small quantity of steamed custard and a little fruit juice. Still later, 
a cereal evening meal may be added. 

In all baby feeding regtilarity b most essential, and by the time the 
infant is iQ months old he should be having three meab a day — ^breakfast 
8 a.m., dinner 12.30 and tea 4.30. One to one and a half pints of milk a 
day should be given in addition, and thb should l>c taken as a drink at 
breakfast and tea, and a cupful should be given before going to bed at 
6.30. No food b to be permitted between meab. 

The foods most suitable at thb age may be taken from the following 
Ibt. It will be noticed that very sweet foods such as ^ams, jellies and cakes, 
are not included, and these should be avoided until the child b about 2; 



WBANINO AN INFANT 277 

cooked meat other than mince should not be given until the child is over 
18 months. Pastries, condiments and cheese must be avoided. 

Cereals. Toast, bread (a little), toast fried in bacon fat, rusks and por- 
ridge. 

Fats. Butter and dripping in fairly liberal quantities. 

Meat foods. Eggs, lightly boiled, poached or scrambled (not fried). Vege- 
table soups and chicken broth, irish ste^v, minced freshly cooked 
beef and mutton, steamed fish and boiled chicken. 

Vegetables. Boiled mashed potatoes, carrots and turnips. Cabbage and 
cauliflower, vegetable marrow and spinach. 

Puddings. Milk puddings, steamed custard and boiled suet puddings. 
Cooked apple, the pulp of cooked plums and prunes. 

Fruits. Raw apple, minced unless the child will masticate it thoroughly. 
Orange juice, and skinned and stoned grapes. 

It is very important to teach the child to cat deliberately and not hurriedly ; 
to masticate thoroughly and not to swallow until quite ready. Drink should 
be taken between mouthfuls only. 

Between the age of i8 months and 2 years the child ought to be taught 
to speak correctly, to walk, to control and regulate micturition, to have 
regular habits of bowel evacuation, to wash his hands before eating and 
to clean his teeth. 

He requires regular meals and regular sleep. A child of this age usually 
wakens about 6; he should immediately empty his bladder, and may have 
a drink of water or milk and water; he must stop in bed without disturb- 
ing other people until 7.15, but he may have a toy to play with or a book 
to turn over the pages. At 7.15 he will be washed and dressed ready for 
breakfast at 8. After breakfast he should immediately have an action of the 
bowels before play or other interest can be entertained. He may play and 
be amused until 10.30 when he should be put to rest in his perambulator 
in the open air. He will sleep for an hour or more, but he may not get up 
until 12 noon, when he should empty his bladder, be washed and prepared 
for dinner at 12.30. 

Dinner should take nearly an hour, and he must sit quietly until 2, 
when he may be taken out in his perambulator until 4 o’clock. Tea is at 
4.30, and after tea he may play or be amused until 6, but this play should 
not consist of excited romping or he will be kept awake. At 6 o’clock he is 
bathed and prepared for bed; he may have a cup of milk, cocoa or broth 
and a finger or two of toast or a biscuit with it. He should be lifted to 
pass urine about 9.30 — this ought to prevent his being disturbed during 
the night, and he should sleep all night. 

After 1 8 months, tea may be made a little more interesting by the 
addition of jam, but pips should not be allowed, and one piece of plain 
ciikc may be given. Sweets should not be eaten between meals, but one 
or two sweets may be added to the midday meal. 



Chapter i8 

Elementary Dietetics 

Diet in diabetes, nephritis, cardiac conditions, malnutrition, peptic ulcer, hypo- 
chlorkydria and kyperchlorhydria, jaundice, constipation and colitis — Calcium and 
iron diets — Diet in dejicietuy diseases 

THE DIETETIC TREATMENT OP DIABETES 

D iabetes mellitus is a constitutional disease in which carbohydrate 
metabolism is defective. The islets of Langerhans are disordered 
so that the internal secretion of the pancreas is diminished, the 
glycogenic function of the liver is disorganized so that sugar cannot be 
stored, and the percentage of blood sugar is higher than normal. In order 
to remove this sugar from the blood large quantities of sugar-laden urine 
arc excreted and the tissues of the body arc thus deprived of fat, owing to 
the very rapid combustion that takes place. 

The chief symptoms are wasting and hunger, thirst, glycosuria, polyuria, 
and the presence of acetone and ketone bodies in the urine. The danger of 
diabetes is coma, which is brought about by the retention of acetone and 
ketone bodies in the tissues. 

Treatment is mainly dietetic, and aims at providing a diet of sufficient 
Calorie value to supply the needs and maintain the weight of the body and 
permit the patient to carry on his usual mode of life without increase of 
the blood sugar beyond the normal limits of 0.9-0. 1 2, or the reappearance 
of sugar in the urine. 

The treatment is divided into three parts: 

(i) A period of preliminary starvation; during this time the pancreas 
is at rest, glycosuria is relieved and the blood sugar decreased to normal. 

(2) A period lasting about 2 weeks follows in which the amount of diet 
is slightly increased, the effect on the blood sugar content noted, and the 
urine tested for sugar. 

(3) A final period, during which the amount of diet is increased .to supply 
the needs of the body, and insulin is added if necessary. 

Formerly the limited amount of diet a patient on diabetes could take was 
the difficulty experienced in treating this condition. Then followed the dis- 
covery of insulin and its effect on the treatment, which enabled more sugar 
and starch to be taken so that a patient could have the amount of food he 
required in order to carry out his work and live a comparatively normal 
life, but at first the difficulty of giving a sufficiently varied diet was experi- 
enced, and it was partly to meet this difficulty and also to help patients 
plan their own diets that the Line Ration Scheme was introduced by Dr. 
Lawrence. This scheme is largely used by patients who arc treated in their 
own homes, and it is also in use in many hospital and nursing home units. 
It will be found mentioned in the section in which diabetes is described 
on p. 438. 

At the present time, when the services of specially trained dieticians 
are available in hospitals and elsewhere, it is becoming increasing practice 
for the physician to prescribe the diet in grammes of carbohydrate, protein 

278 



THE DIETBTIO TREATMENT OF DIABETES 279 

and fat. He may, for example, presmbe 150 grammes of carbohydrate, and 
70 eaudi of protein and fat. The dietician prepares the meals, and if the 
patient is not on insulin the nurse will give the amount of carbohydrate 
prescribed^ evenly, at each of the four meals of the day. When the patient 
IS on insuhn, she will concentrate the amount of carbohydrate prescribed 
into the two main meals before which insulin is given. 


NEPHRITIS 

Acute nephritis due to bacterial infection necessitates complete rest 
for the kidney. In these cases the urine will be found to contam blood, 
and will probably be very much diminished in quantity. 

In the dietetic treatment the minimum of protein will be given and fluids 
will be limited to 2 pints in 24 hours until the urine contains less blood and 
albumin, showing that the disease is abating and the degree of inflam- 
mation of the kidney becoming less severe. Some physicians eliminate all 
protein, including milk protein, for the first ten days, giving only glucose 
up to half a pound a day, in lemonade or barley water. Other physicians 
give a pint of milk and a pint of water during the 24 hours so that the 
patient is receiving a litde protein. 

The amount of fluid is increased as the condition becomes less acute, 
and after 2 or 3 weeks 2 pints of milk and i pint of water may be taken. 
Later, such things as Benger’s food and arrowroot, milk pudding, and 
bread and butter, may be added to the diet; but protein, particularly meat 
protein, and salt and condiments should be omitted until convalescence is 
thoroughly well-established. 

Chronic nephritis is divided into two main types, in one of which, 
known as chronic parenchymatous nephritis, the main substance, that is the 
tubules of the kidney, is involved. The kidney is large and pale and the 
patient also is swollen and pale because he is anaemic and his muscles are 
flabby and oedema is present. His urine contains large quantities of albu- 
min which represent heavy loss of protein to the body. 

Treatment. In the dietetic treatment of this form, the loss of protein has 
to be made good, so that a high protein diet is administered — an example 
of this diet is given below. The protein used should include eggs and fish, 
and meat. Fat should be limited as the body tissues deprived of protein 
find it difiicult to use fat, and ketosis may develop. Because of the oedema, 
fluids should be restricted to 35-40 ounces a day. In some cases of oedema 
salt is omitted or limited. 

A high protein diet contains from 100 to 120 grammes of first-class 
protein; some second-class protein may also be given, though this is not 
invariably included. 

The following is an example of the type of meals a patient may have 
when on this diet: 

Breakfast. One or two eggs or 4 ounces of fish — bread (unlimited) and 
butter, tea with inilk and sugar. 

Dinner . Lentil soup or soup made with milk. Meat 4 ounces or fish 6 
ounces. V^etables (peas, beans and lentils contain protein but 
it may not be possible to give this of vegetable every day 
as it renders die diet monotonous). Milk pudding or egg custard. 

Tea. One e^, or some cheese or meat sandwiches may be given (it is 



q8o elementary dietetics 

usual to give i ounce of minced meat or chicken in sandwich 
form). Tea with milk and sugar, bread (unlimited) and butter. 

Supper. Meat or fish as at dinner, bread (unlimited) and butter, milk 
pudding or a drink of milk. 

Chronic interstitial nephritis* In this condition the interstitial tissue 
rather than the tubules of the kidney is affected. The kidneys arc small 
and red in character. This disease is associated with arteriosclerosis and 
hypertension and high blood pressure. The patient may be passing large 
quantities of pale urine because the kidneys fail to concentrate, and it may 
contain only a trace of albumin. On examination of the blood the urea 
content is markedly high, as the urinary waste products arc being retained 
to a very injurious extent. Uraemia frequently complicates this type of 
chronic nephritis. 

The treatment consists of a low protein diet, in order to lessen the reten- 
tion of urinary waste products in the blood. Apart from this the patient 
should lead an easy uneventful life as described in the treatment of high 
blood pressure. 

A low protein diet contains less than 6 o grammes of protein. The 
meals a patient may have when on this diet arc indicated in the following 
example: 

Breakfast. Fruit and one or two slices of bread and butter. Tea with 
milk and sugar. 

Dinner. A little chicken or fish soup. A moderate amount of protein — 
2 or 3 ounces of fish, two vegetables, such as potatoes and green 
cabbage. Stewed finit or fruit salad or cornflour mould made with 
fruit juice or a cereal such as tapioca cooked in fruit juice (not in 
milk). 

Tea. A little bread and butter, salad or jam. Tea, with milk and sugar. 

Supper. Salad and fruit and bread and butter with lemonade and glucose 
to drink. 

Bread is limited in a low protein diet as it contains considerable 
protein. Preparations of fat-soluble vitamins A and D may be 
required as the patient is having little fat because he is deprived of 
red meat and eggs. 

DIET IN GOUT AND RHEUMATISM 

In all cases of acute heart disease a low diet, usually milk only, is adopted. 
In chronic heart disease a comparatively low and easily digested diet is given. 
The meals chosen should be small in quantity and given at frequent inter** 
vals of 2 or 3 hours. Such articles of diet as milk, easily digested proteins 
such as fish, and very well cooked farinaceous foods arc employed. It is 
advisable for the diet to be fairly dry, fluids being given between rather 
than with meals, as one of the main principles of treatment is to avoid 
distension of the stomach, because its proximity to the heart would give 
rise to indigestion, palpitation and cardiac embarrassment. 

Stimulating fluids such as tea, coffee and alcohol should as far as possible 
be avoided, but a small cup of weak tea may be given on awakening in 
the morning as it relieves nausea and the same may be taken after the 
early afternoon nap. 



DIET IN OOUT AND RHEUMATISM 28 1 

When oedema is present in heart disease fluids are restricted and salt is 
restricted or eliminated from the diet. 

Hyperpiesis. By this term high blood pressure is understood, and in 
the middle-aged this is most commonly associated with arteriosclerosis. 

Treatment. In hyperpiesis the nutrition must be maintained, and there- 
fore drastic lowering of the diet is not indicated. As a rule red meat pro- 
teins are limited to once a week, flsh and chicken being taken on other 
days. In middle age there is a tendency to obesity, and as cases of high 
blood pressure wiU be taught to lead a quiet moderately uneventful 1& 
they may tend to become &t; this is to be avoided, and therefore carbo- 
hydrates should be moderatdy restricted to this end. Stimulants which 
may increase the rate of the circulation arc inadvisable; alcohol should not 
be taken and tea and coffee only in strict moderation; if the patient can 
be persuaded to accept the restriction, and the deprivation is not too 
seriously felt, such beverages should be limited to a cup of wctik china 
tea twice a day. 

The patient should be advised to lead a very even life and go to bed 
early and rise as late as possible; a day in bed a week is very advisable, 
and if the patient has a tendency to obesity the day in bed a week may be 
a day spent on orange juice only. Life should be as free as possible from 
worry and anxiety. 

The dietetic treatment and the general mode of life, advised above for 
cases of hyperpiesis, can be applied to cases of arteriosclerosis and aneurysm 
of the large vessels. 


DIET IN CARDIAC CONDITIONS 

The diet which is described as purin-free, is frequendy advised in cases of 
gout and chronic rheumatism. The inteitials of animals contain complex 
purin substances known as nucleo-protcins. The vegetables classed together 
as legumes — j>eas, beans and lentils — and other vegetables, including 
asparagus and onions, contain vegetable purins and are included in the 
food contraindicated in gout and rheumatism. Foods which can be freely 
used and considered purin-free include eggs, milk, milk products, cereal 
foods, cabbage, lettuce and cauliflower; and potatoes can be used in 
moderation as these contain only very small quantities of vegetable purin. 

In acute rheumatism diluted milk is the main diet, especially while 
the temperature is high. Lemonade and barley water can be given freely 
as the fluid intake ought to be increased because perspiration is very 
marked in these cases, and the loss of fluid requires to be made good. When 
the acute febrile stage is over chicken broth and milk foods may be added 
to the diet. 

In chronic rheumatism, myositis and fibrositis, the diet should 
be purin-free, and only those foods mentioned above should be used. Rich 
fat food shoidd be avoided, particularly pastry, fat fish such as herring, 
salmon and saidine, highly spiced foods and prepared sauces and stimu- 
lants. 


MALNUTRITION 

Generally speaking malnutrition is associated with loss of weight, and 
with this factor digestive disorders are a very primary cause. Absence of 



S8S ELEMENTARY DIETETICS 

appetite will cause loss of weight and a nurse may fadp a physichm in 
finding out whether there is definite disinclination and lack of desire for 
food, or whether the small amount the patient is taking is due to his avoid- 
ing food for fear of painful or unpleasant consequences. The former is true 
lack of appetite, in the latter case appetite may be normal. 

Disease of the stomach and intestine (see peptic ulcer diet) and disease of 
the colon are very usual causes of loss of weight. The possession of too few 
teeth would make digestion misatisfactory and so give nse to loss of weight. 
A septic focus somewhere in the body will by absorption of toxins firom this 
focus give cause to toxaemia and result in loss of weight. The fear of getting 
fat may become an obsession, even in quite young people, while in others 
their profession may demand the acquisition of a slim figure. Such 
psychological factors in regard to wasting and malnutrition cannot be 
reasonably overlooked to-day. 

In taking the history of a patient suffering from malnutrition, habits of 
life should be investigated, particularly with regard to the amount of 
food taken and the amoimt of fluid, the regularity as to times of meals and 
the time allowed for meals, the times for retiring and rising, the amount 
of physical exercise taken during work and play, the amount of 
rest available and of sleep obtained, and whether sleep is continuous or 
interrupted. The regularity of bowel action and the action of the skin and 
kidneys should also be carefully considered. 

An acute febrile condition is associated with loss of weight, but this 
weight will usually be replaced during convalescence. The so-called wast- 
ing diseases, including tuberculosis, demand a diet of high calorie value. 
In exophthalmic goitre the patient may have a normal appetite and eat 
well, and yet lose weight owing to the increased rate at which metabolism 
is being carried out. 

The treatment of malnutrition depends entirely on the cause. A nurse may 
be able to assist by tempting the appetite, and the rules for feeding a 
patient (on p. 267) may suggest how she can make his food appetizing 
and the diet varied. Whenever a diet of high calorie value is to be given, 
milk, cream and butter should be added as far as the appetite and good 
will of the patient will permit. Mealtimes should be free from worry and 
anxiety. A rest period of thirty minutes during which the patient lies on 
his bed totally unoccupied and relaxed should precede each meal, and a 
rest of an hour and a half or two hours should follow the two main meals 
of the day. 

Obesity. As in the case of Pharaoh’s lean and fat kine, so humanity is 
di^xised to variations of weight, and in those inclined to excessive 
weight a sedentary life, excessive meals and quite moderate quantities of 
alcohol tend to produce obesity. 

Internal secretions control mental and physical activity to a very great 
extent, and thyroid, adrenalin, and ovarian secretions, led by the pituitary 
body which may be looked upon as the brigadier general of the force, play 
a very active part in the phyncal well-being of each of us. It is wdl known 
that some disturbance of the pituitary gland results in the deposit of fat in 
the tissues. The fat boy in Pickwick probably had deficiency of secretion of 
the anterior lobe of his pituitary gland. The decrease which takes place in 
the production of internal secretions controlling ovarian and uterine 
functions at the menopause also causes a tendency to obesity. 



MALNUTRITION 283 

Treatmmt. Many persons take to injudicious slimming today, with con- 
sequent harm to the body, and it is uierefbre advisable for every woman 
who is in the nursing profession, even in the capacity of a junior probationer, 
to realize the fundamental factors upon which the diet of ob«ity may be 
undertaken with comparative safety and without harm to the subject; and 
to realize further that in the majority of cases it is inadvisable to limit the 
diet to any extent except under the direct observation of a medical 
practitioner — and particularly is this so in the case of women over forty. 

The principles governing the dietetic treatment of obesity are: 

(1) The provision of a diet of low calorie value in order to reduce the 
weight — cainjohydrates therefore should be restricted. 

(2) To incorporate into that diet sufficient food to satisfy the appetite, 
prevent himger and supply roughage sufficiently for the avoidance of con- 
stipation. 

(3) The provision of the necessary minimum but adequate amount of protein 
(at least 3 ounces), and the administration of sufficient fat to act as a lubri- 
cant and provide enough of vitamins A and D, and the provision of 
sufficient carbohydrate to avoid the production of ketosis. 

(4) Sufficient fluid should be taken to avoid thirst, but it should be 
given between and not with meals. 

Adequate exercise ought to be undertaken. 

The rate of loss of weight will depend on the intake in food and the out- 
put in work and energy. If, for example, a working woman, considerably 
overweight, desires to reduce, she might safely do this on an intake of 
1,500 to 1,700 Calories instead of the normal one of over 2,000 and in 
such a case might expect to lose about 2 pounds per week. This rate of loss 
would be considered safe; more rapid loss, say at the rate of 3 pounds a 
week, could be maintained by a patient on less diet, spending most of her 
time resting, but for the former a rate of loss of 2 pounds per week would 
be all that should be attempted. 

A patient being allowed about 1,500 Calories might have a diet similar 
to the following examples of meals: 

Breakfast. Tea, with milk but no sugar. Two vita wheat biscuits. One 
boiled egg and a little butter (about J ounce). 

At II a.m., in order to give something to sat^y the patient and prevent 
his desiring to eat too large a meal at midday an apple may be 
given. 

Dinner. Two ounces of meat or 4 ounces of fish. A large helping of green 
vegetables and a second vegetable, either parsnips, haricot beans, 
peas or lentils. 

Tea. Tea with milk but no sugar. Two vita wheat biscuits and J ounce 
of butter and some salad. 

Supper. Two ounces of lean ham, or 3 ounces of fish or some cheese. 
Two vita wheat biscuits. Salad, fresh fruit and lemonade 
sweetened with saccharine. 


PEPTIC ULCER (see also page 379 ). 

Both gastric and duodenal ulcers are included under this heading ^ 
an ulcer usually occurs on the parts exposed to the irritation of gastric 
juice. 



284 ELEMENTARY DtETKTICS 

The symptoms of peptic ulcer vary slightly according to the locality, 
and as a general rule the patient will complain of indigestion, which may 
be continuous or recurrent, while the pain varies with die site of the ulcer. 
In the dtufdenal type it comes on at a fairly long interval after a meal and is 
relieved by taking food or alkalis. In gastric ulcer the pain is more in the 
middle line, comes on a short time after a meal, and is relieved by vomiting 
and also by the administradon of an alkali and bismuth. 

The dietetic treatment of gastric and duodenal ulcer is very similar, 
and in practically no other condidon docs dietetic treatment occupy such 
an important posidon. It is essendal therefore that nurses in charge of 
these cases should have a clear knowledge of the principles governing this 
mode of treatment. 

(1) The diet should be bland non-irritating, and it should not sdmu* 
late the flow of gastric juice, because, as already mentioned, this acid 
fluid acts as an irritant to the ulcerated area and so prevents healing. The 
principles applied, therefore, must be those of rest in all its phases, par- 
ticularly as regards the physiological chemical activity and the mechanical 
movements of the organ in order to reduce the work and so rest the diseased 
part. 

(2) The amount of food given must be small in quandty and the intervals 
between feedings should be very short so that there is no intervening 
time for the accumulation of gastric juice. 

(3) The protein used should be one that is easily combined with the hydro- 
chloric acid, so that the acid content of the stomach is readily fixed by 
it. For this purpose milk protein is advised by Dr. Lenhartz. 

(4) The fat content of the diet should be high, because fat acts as a deter- 
rent to gastric movement, and so help>s to allay spasm. 

(5) Whenever the dietetic treatment has to be sustained over a consider- 
able time, it is important to ensure a good calcium content and an adequate 
vitamin supply and the Calorie value of the diet should be reasonably high. 
To supply vitamin C, which is invariably lacking in this diet, strained 
orange juice may be given. 

Lastly^ many of the peptic ulcer dietaries employed today are modifi- 
cations of two very well-known ones briefly described below — Lenhartz 
and Sippy. (For Meulengracht’s diet, sec p. 382.) 

The Lenhartz Diet. This was first introduced in 1904 and has been 
modified since. The principles already given in the preceding pages arc 
employed in the administration of this method. Dr. Lenhartz used egg 
protein. The regime began by giving one egg per day, increasing by half 
an egg per day until at the end of a week four eggs arc being given. Later, 
the eggs are r^uced as fish is added to the diet. 

At the outset 3 oimces of milk are given on the first day, to be increased 
by I ^ ounces per day until the patient is having about 1 2 ounces by the 
end of the first week. On the eighth day ^ ounces are added and subse- 
quent increases of an ounce per day are added imtil the patient is receiving 
23 ounces. 

Sugar and starch. Six drachms of sugar are given on the third day, gradu- 
ally increased until the patient is having 14 drachms at the end of 3 weeks. 
Two drachms of arrowroot arc given on the sixth day and continued 
throughout the second week. Three ounces of blandnange are given on the 
eighth day, and slightly increased during that week. Rusks may be given 



PEPTIC ULCER 285 

on the ninth day, about thrceqaarters of an ounce, and increased until 
the patient may be having four ounces of rusks at the end of a fort- 
night. 

FeA. Three-quarters of an ounce of butter is given on the tenth day, i 
ounce on the eleventh day, and ounces on the twelfth and subsequent 
da^. 

Thirst is relieved by salines, until the patient is having sufficient fluid 
for this purpose. 

Calorie value. During the first week the Calorie value of the food given 
is a little below i ,000. This results in loss of weight; during the second week 
it reaches 2,000. Many modifications may be made by the end of the second 
week and the diet could quite easily be arranged as a series of regular 
meals — ^for example: 

Breakfast — 8 a.m. Poached egg, two or three rusks with butter, J pint of 
milk. 

Light lunch — 10.30. Two buttered rusks and J pint of milk. 

Dinner — i p.m. Steamed fish with butter and rusks, steamed custard 
■with sugar, and water to drink. 

Tea — 4 p.m. A meal similar to breakfast. 

Supper — 7 p.m. Blancmange or milk pudding, rusks and butter, ^ pint 
of noilk. 

Light nourishment — 10 p.m. Five to six ounces Benger’s food. 

During night — One or two drinks, 4 or 5 ounces of milk may be given. 

Sippy’s diet was introduced in 1915. This treatment aims specially at 
keeping the stomach free of hydrochloric acid and is carried out by the 
administration of fat such as cream and olive oil, and by the giving of 
atropine before feeding followed by large doses of alkalis after feeding. 

Three ounces of a mUk cream mixture are given every hour from 7 a.m. to 
7 p.m. Lightly cooked eggs are added after a few days, and well cooked starchy 
foods at the end of a week. 

The alkalis generally used are sodium bicarbonate 10 grains, mag- 
nesium carbonate 10 grains, alternately with bismuth carbonate ;o grains 
— the administration of magnesium and bismuth being so regulated that 
the bowels are kept acting regularly and diarrhoea and constipation 
avoided. Half an ounce of olive oil is given before alternate feeds and 
i/i5oth of a grain of atropine hypodermically before the other feeds. 

Advice to convalescent patients, (i) The regular habits formed in 
hospital should be carefully observed and continued and meals should be 
sm^, regularly taken, and the intervals between them short. (2) All food 
should be taken very slowly and well masticated before swallowing. (3) As 
far as possible fluids should be taken between meals rather than with meals. 
(4) All foods cooked in fat should be most rigorously avoided. (5) The 
hygiene of the mouth should be carefully carried out at least twice a day 
and regular visits paid to the dentist. (6) A regular action of the bowels is 
essential every day, and the patient should realize that the action must 
be adequate, and that a small constipated stool is not sufficient. (7) If 
possible the patient should not smoke, but if this is a very great deprivation 
he may be permitted one or two cigarettes a day. 



286 


ELEMENTARY DIETETICS 


HYPOCHLORHYDRIA 

Deficiency of hydrochloric acid in the gastric secretion is met with in 
pernicious anaemia and in other secondary anaemias; it is marked in 
advanced cases of cancer and occasionally occurs in normal persons. 

Dietetic treatment. Easily digested foods should be chosen, and any 
foods which are known to inhibit gastric digestion should be avoided as 
far as ]x>ssiblc. Small meals should be taken and the food should be finely 
broken up by chopping and mincing whenever possible. Toast should be 
taken in preference to bread, as it is easier to masticate toast. Condiments 
and extractives which help to stimulate the gastric juice may reasonably be 
used. The administradon of hydrochloric acid before and during meals is 
advised. 

HYPERCHLORHYDRIA 

An excess of hy'drochloric acid in the gastric juice occurs in most forms 
of dyspepsia and in cases of peptic ulcer. 

In the dietetic treatment everything which will help to fix the 
hydrochloric acid is used, and therefore milk, egg and fish proteins are 
valuable. All ardcles likely to stimulate the secredon, such as condiments 
and spices, extraedves and alcohol, should be carefully avoided. 

JAUNDICE (see also page 392). 

This is more often a symptom of a disease than a disease in itself. It is 
generally divided into obstructive jaundice and non-obstruedve; apart 
from infective catarrhal jaundice, and haemolytic types, most forms arc 
due to obstruction. In these cases the bile does not enter the duodenum 
as it should and is being absorbed by the blood stream, giving rise to the 
symptoms which are present. 

The dietetic treatment aims at the relief of symptoms. A light easily 
digested diet should be given with liberal supplies of fresh fruit and 
vegetables; fats should be avoided and in some cases even milk fat cannot 
be taken; milk puddings should be made with skimmed milk; meat 
extracts, condiments and stimulants should not be taken. Bland fluids 
should be given freely in order to aid the excretion of bile, which is present 
in excess in the blood, by means of the kidneys and the skin. The bowels 
should be kept acting regularly, since constipation is apt to occur owing 
to the absence of bile, which is normally a stimulant to peristalsis. 

ANAEMIA (see also page 359). 

There arc a number of varieties of anaemia, but in all cases, whether it 
be primary — a disease — or secondary, following haemorrhage or accom- 
panying some cachexial condition, there is either diminution in the quan- 
tity or m the quality of the blood. All cases of anaemia, therefore, require 
a good nourishing diet, but it is in the treatment of pernicious anaemia 
that dietetic treatment has proved so particularly valuable. 

Pernicious anaemia. In the treatment of this condition liver diet is 
now universally employed. This was first instituted by Drs. Minot and 



ANABMIA 387 

Murphy, who found that on a diet of liver cases of anaemia improved; as 
much as half a pound of raw liver a day was administered, preference being 
given to calf’s liver, though pig, lamb and ox liver may be used. At first 
there was considerable difficulty in getting patients to take the desired 
amount of raw, or almost raw liver, and many ingenious cooks invented 
special dishes — one, of world renown, is the liver cocktail, which contains 
half a pound of raw liver crushed through a sieve, having its flavour dis- 
guised by orange and lemon juice, tomato juice, and various spices, sauces 
and condiments. 

At the present time valuable preparations of liver extract are available 
and may be substituted for raw liver. 

Further investigation on patients proved that the marked improvement 
obtained on this diet was due to a special ferment contained in the lining 
of the stomach; this ferment was stored in the liver — hence the value of 
raw liver. Physiologists, however, continuing their investigations decided 
that the lining of the stomach containing the actual ferment might act 
as an alternative diet to the liver in which the ferment is merely stored. 
It is this investigation which has resulted in the administration of hog’s 
stomach ^ventriculin). 

In addition to the administration of liver large quantities of hydrochloric 
acid are given, half to one drachm mixed in lemonade is taken before 
and during meals. The diet should also contain large quantities of fresh 
fruit and green vegetables and tomatoes. By ‘a large quantity’ at least half a 
pound of fruit and threequarters of a pound of vegetables should be 
understood. 

Fats and carbohydrates should be limited; a great deal of animal starch is 
being given in the liver as glycogen, and owing to the tendency of cases 
of pernicious anaemia to develop lardaceous degeneration of some of the 
hard organs, including the liver and kidneys, fat should be limited to 
about 2 ounces per day — therefore bacon, cheese and cream should be 
avoided as far as possible and milk should be used only sparingly. 

DIET IN CONSTIPATION 

The causes and symptoms of this condition aie dealt with on p. 387. 
The dietetic treatment depends on whether the subject is suffering from 
tonic or atonic constipation. 

For atonic constipation a high residue diet will be given, and this 
means that the patient is to be riven as much fruit and green vegetables 
as possible with plenty of carbohydrate foods. 

A low residue diet is employed in the treatment of tonic or spastic 
constipation. In this diet all fruits and green vegetables are omitted and also 
foods such as brown bread. Care has to be taken in the preparation of the 
diet to see that no harsh particles arc included. Milk and cream may be 
given. 

When the patient is convalescent and b first allowed a little fruit it 
should be pas^ through a sieve so that it is as finely broken up as possible. 
A raw apple grated and pressed through a sieve is an example of what is 
first given. 

As patients who arc on a non-residue diet for some time may not get 



288 ELEMENTARY DIETETICS 

enough vitamins B and C, small quantities of strained orange juice should 
therefore be given, and some preparation containing vitamin B, such as 
marmite or yeast. 


COLITIS (see also page 385). 

Colitis may be acute or chronic; in ulcerative colitis the stools contain 
blood and mucus and are frequently passed. 

The diet in these cases varies with the treatment adopted by the phy- 
sician; in some instances a low residue bland diet is employed and care 
is taken to eliminate all irritating particles by creaming and straining the 
foods used. Another method adopted is the restriction of fats giving a litde 
bovril and marmite and dry toast first; then, as improvement is manifested, 
gradually building up a moderate, light, fat-free diet; but milk as an article 
of diet and eggs are not given until fat is added in the final stages of 
treatment. 

More recendy cases of acute colitis with frequency of stool as a symptom 
have been treated by Moro’s apple pur6e diet; raw apple is grated and 
pressed into a mould and allowed to stand, and the patient is given as 
much as he will eat of this, and nothing else, for every meal for from 2 to 4 
days. It appears to be successful as the stools decrease from 8 or 10 to 
I, 2 or 3 a day, the character of the stool improves and the patient begins 
to make progress. 


HIGH AND LOW CALORIE DIETS 

A low calorie diet is found in the example given on page 283 in a diet for 
obesity. This may contain as litde as 1,000 Calorics and the patient will 
lose weight on this diet. 

A high calorie diet is employed in order to produce an increase in body 
weight; it is given during convalescence from disease and in the treatment 
of certain wasting diseases, as in tuberculosis. 

When providing a high calorie diet, sugars, starches and fats arc increased. 
Sugar may be given as glucose and brown sugar used in preparing fruit 
drinks, as well as in sweetening foods; all foods rich in starch, such as 
bread, cakes, puddings and sweets arc employed, and fat is provided in 
the form of fat meats and as milk, cream, butter and cheese. 

In the provision of a high calorie diet in the treatment of pulmonary tuberculosis^ 
fat is given in large quantities, as the object is not only to increase the 
weight of the patient, but to provide a diet rich in vitamins A and D 
as well. Many patients do not tolerate fat well and some are disinclined 
to take sweet folxls, so that in every instance the wishes of the patient and 
his likes and dislikes have to be considered; for this reason it is impossible 
to lay down a diet table suitable for every occasion, but the following 
dietary for one day is suggested as an example: 

Breakfast. Two or three ounces of cereal with cream and sugar. Two 
rashers of bacon and two eggs (fned). Toast, butter and marma- 
lade. Coffee or tea, with milk or cream and sugar. 

Midmorning. A milk drink of 6 ounces with i ounce m cream. Biscuits 
and butter with marmite (the latter being employed to give 
the necessary amount of vitamin B in a diet of hi^ calorific 
value). 



HIGH AND LOW OALORIB DIETS 289 

Lofwk — I p.m. Meat or fish, about 6 ounces. Potatoes, fried or baked; 
or boiled potatoes mashed with butter and milk may be given. 
Vegetable, with butter or sauce containing cream or butter. A 
steained pudding, amjde charlotte, baked custard or milk pud- 
ding, or bread and butter pudding are all excellent. (A steamed 
pudding with jam sauce or white sauce is of very high calorie 
value.) A sweetened fruit drink. 

Tea — ^4.30 p.m. Tea with milk and sugar, bread and butter, and jam 
sandwiches and cake. 

Supper — 7.15 p.m. Soup, thickened and containing cream. Savoury such 
as cheese souffle, macaroni cheese, or potato pie with thickened 
gravy. A pudding (such as one of those suggested for lunch). 
Cheese, butter and biscuits. (Three courses may be given, but the 
alternative course had better be soup or cheese.) A sweetened 
fruit drink. 

At night. A milk drink of 6 ounces with i ounce of cream biscuits and 
butter. 


DIETS RICH OR LOW IN CALCIUM AND IRON 

Diet rich in calcium {high calcium diet) and diet in which the calcium con- 
tent is low {low calcium diet) may be ordered. In certain abnormal con- 
ditions of the body the utilization of calcium may be disordered and special 
dietetic care may be required to estimate the intake and output of calcium 
by means of a diet described as — a calcium balance diet. 

The fo^s rich in calcium are milk, eg^ and cheese; these will be given 
liberally in a high calcium diet and omitted from a diet of low calcium 
value. 

In the nursing care of patients who are on a low calcium diet, low iron 
intake diet or a calcium balance diet all the water taken into the body has to 
be distilled. The utensils used by the patient for feeding purposes are 
washed in distilled water, all food is cooked and prepared with it, the 
patient’s teeth should be deaned with it, and if he has to have an enema 
or a saline this also must be prepared with distilled water. 

KETOGENIC DIET 

A ketogenic diet is rich in fat. It renders the urine highly acid and 
causes acidosis. It was used in the treatment of chronic infections of the 
urinary tract due to B. coli, but is rarely employed today, having been 
superseded by mandelic acid treatment (see p. 403). 

The diet prescribed may contain 50 grammes of protein, 250 grammes 
of fat and 20 grammes of carbohy(£mte. The fat is given in the form of 
butter, cream and bacon fat. 

DEFICIENCY DISEASES 

The group of diseases described as deficiency diseases indicate that the 
cause is due to the absence of certain vitamins present in food and essential 
in diet to health and wellbeing. These diseases are frequently caused by 
dietetic arors, and the history of the diet should be very carefully investi- 
gated and suitable foods administered. 



290 

Vitamin 

A 


B Complex; 


C 


D 


K 


EL&MENTARY DIETETICS 


Sam$ 

Cod4ivcr and halibut* 
Uver oils, animal fats, 
milk, butter, cream and 
Carotene (less 

Gcrminatmg seeds and 
cereals, peas, beans and 
lentils, yeast, eggs, meat 
and liver* 

Juices oi citrous fhxits, 
tomato and potato, raw 
green vegetables. Syn- 
thetically prepared as 
asmbie acid. 

Cod-liver and haUbut-liver 
oils, milk, butter and 
cgg*yolk. Abo obtain- 
able as irradiaUd erga^ 
steroL 

Green leaves, pig’s liver. 


FttneHon 

Maintains nutrition 
and preserves the 
healm of mucous 
membranes. 


Preserves the health 
of nervous tissue. 


Maintains nutrition. 


NccoBai^ for the as- 
similation of cal- 
cium and the for- 
mation of bone. 

Needed for clotting 
of blood. 


(See also chart of vitamins at end of book.) 


Jjm of weight, ten- 
dency to catarrh 
and sep^ xero- 
phthalmia. 

Bi. Digestive db- 
orders, polymcu- 
ritis, beri-bm. 

Bd. Pellagra. 
Scurvy. 


Rickets. 

Osteomalacia (in 
adults.) 


Gives prolonged co- 
agulation time. 


Rickets produces constitutional changes. There is deficiency of calcium 
in the bones and dentition is delayed. The infant is pale and flabby. He 
may be irritable and restless, and may have convulsions, diarrhoea and 
night sweatings. Rickets docs not usually develop until after the age of six 
months, and it responds to the administration of cod-liver oil and irradiated 
ergostcrol in which vitamins A and D are freely contained. The dose of 
vitamin D required to cure rickets is 2,000 to 3,000 I.N. daily. 

The diet includes fresh cow’s milk and cream, orange juice, fresh fruit, 
fruit pulp and green vegetables. Bacon and butter should be given liber- 
ally. Lightly cooked eggs and protein — fish protein and red beef gravy 
from underdone beef, and freshly cooked red beef minced may be used. 
Carbohydrates should be limited, especially sweets and cakes. The follow- 
ing is a sample day's dietaiy for an infant aged eighteen months with rickets: 

Breakfast — 8 a.w. Two ounces of porridge and J ounce of cream, Qjaartcr 
of a slice of bread fried in bacon fat with a small piece of fat 
bacon. Five ounces of milk. 

Light lunch — 10.30. Four ounces of milk and a buttered rusk. 

Dimer — i p.m. Three ounces of freshly cooked minced beef— plenty of 
red beef gravy, ^ ounce of breadcrumbs and i ounce of potato. 
An oimcc of weU-cooked minced cabbage. A little custard and 
fruit pulp. Water to drink. 

Tea — 4,30 p.m, A lightly boiled egg, 2 well-buttered rusks, or half a 
slice of well-buttered bread cut into fingers. Milk to drink 5 
ounces. 

On going to bed — 6 p.m, A small drink of milk. 

In addition to dietetic treatment an infant with rickets needs fresh air 
and sunshine and good hygienic conditions of living, weight-bearing or 
posture deformities should be prevented. 


Xerophthalmia is a condition in which hardening or kcratinization 
of the cornea occurs. This is due to ddidcncy of vitamin A, and respoi:^ 
to treatment by administration of sufficiently large doses of this vitamin. 



DEFiOIENCY DISEASES 20 1 

Night blindness is due to inability of the retina to adapt itself to 
darkness. Vitamin A is of importance in maintaining this function. 

Scurvy. This disease is due to deficiency of the antiscorbutic vitamin 
and, when it appears, it occurs most commonly between the ages of 6 
and 1 8 months. 

The infant responds rapidly to dietetic treatment. He is usually being arti- 
ficially fed on some p»roprietairy milk preparation devoid of antiscorbutic 
vitamins without having these added to tne diet. Fresh cow’s milk should 
be given and orange and lemon juice, tomato juice and potato cream. 
The infant may be in a very bad state with sore tender gums, his limbs 
may be very tender to tou(^ and he is easily hurt when handled. The 
mouth should be kept very clean arid, if it is difficult to get the food taken 
the child may be fed by the nasal tube. He requires very gentle handling. 
Improvement will occur quickly as the response to treatment is always 
rapid. 

Beri-beri is due to deficiency of thiamin (vitamin Bi.) It is a disease 
characterized by polyneuritis. Two types are described (a) dry beri-beri in 
which muscular wasting and weakness is marked and (b) wet beri-beri 
characterized by oedema; there is aneisarca and ascites. 

Treatment consists in the administration of a well balanced diet. Yeast 
and marmite are given as these two substances contain large quantities 
of vitamin Bi. 

Pellagra is a disease which occurs when the diet is deficient in milk and 
meat, which contain the necessary nicotinic acid or one of the vitamin B 2 
entities. This disease is characterized by symmetrical areas of dermatitis 
on the exposed parts of the body such as the hands and forearms, forehead 
and face. There is loss of appetite, soreness of the mouth and loss of 
weight. 

Treatment. The patient b put to bed and the symptoms are treated. 
He is given a diet rich in milk and eggs, butter, meat, fruit and vegetables 
and liberal doses of yeast. The areas of skin affected should be covered in 
order to protect them from the light which is irritating in thb condition. 


D1£T IN COELIAG DISEASE 

Coellac disease is considered to be due to the inability of the infant to 
absorb fats, a large amount of fat appearing in the stoob which arc large, 
pale and greasy. There b great wasting. 

The dietetic treatment should be of a minimum calorie value, entirely 
devoid of fiit and with carbohydrates limited. Protein forms the base of 
the diet and dried milk, vdiitc of egg, orange juice, green vegetables and 
bananas, as many as 6 or more a day, are given. As improvement be^ns 
carbohy^ates are gradually added and then fats given in small quantities. 

Vitamins A and D are given to prevent rickets and substances which 
help in the assimilation of fats, such as bile salts are prescribed in small 
doses. 



Section 3 

The Administration of Drugs and Medicines 
and Elementary Materia Medica. Poisons 
and Poisoning 


Chapter ig 

Administration of Medicines and Drugs 

The origin and dosage of drugs — Idiosyncrasy and intolerance — Weights and 
measures — Modes of preparation of drugs — Classification of drugs — The pre^-^ 
scription — The safe custody of medicines and drugs — Rtdes for giving medicine — 
Modes of administration of drugs — Inhalations^ including administration of 
oxygen — The use of sera and vaccitus — Chemotherapy 

M edicines and drugs used in the treatment of disease are derived 
from three main sources. The majority are oi vegetable origin^ being 
obtained from the leaves, roots, stems and seeds of plants — as for 
example, digitalis from the leaf of the foxglove, and colchicum from the 
seeds of meadow^ saffron. A fair number of drugs arc derived from mineral 
sources^ principally salts of iron, mercury, arsenic, lead and phosphorus, 
and a few from animal sources — usually the extracts of endocrine organs 
such as the pituitary body, and the thyroid gland, adrenalin from the 
suprarenals and insulin from the pancreas. 

Before a drug can be ordered its dose must be standardized. The majority arc 
standardized by chemical meansj and they are then put up as a solution 
containing a certain percentage of the active principle of the drug. In a 
few instances, however, where the drug is obtainable in a pure crystalline 
form a certain weight of it — c.g. so many grammes or grains or fractions 
of a grain — will be given. 

The other method of standardization is biological^ by which the effect 
of a drug on an animal is determined. 

Having arrived at the standardization of any given drug, its dose for 
the adult is then laid down by the compilers of the British Pharmacopoeia, 
and this is determined by the strength of the drug. A certain dose for the 
adult man is given, but in practice this has to modified according to 
the age of the p)crson, and to some extent according to his size — ^for example 
a large fat man weighing i8 stone will require considerably more than a 
little lean man of 8 or 9 stone. A woman is considered to require slightly 
less than a man, but here again size and weight have to be taken into con- 
sideration. 

A child requires a correspondingly smaller dose than an adult, and in 
practice this is determined in several ways, one of the more common 



ADMINISTRATION OF MEDICINES AND DRUGS 293 

ways of calculating the dose required for a child being by means of Young’s 
rule — ^Take the age of the child over the age plus 12, c.g. 

— =. — i/yth of the adult dose. 

Idiosyncrasy or undue sensitiveness to the action of a drug sometimes 
exists in a person, and is a factor which will materially alter the size of 
the dose to be given. Some people are sensitive to, and can only tolerate 
small doses of, such drugs as aspirin, sodium salicylate, quinine and 
potassium iodide. A dose of ordinary size in these cases produces manifesta- 
tions of what are described as untoward symptoms — in reality symptoms of 
poisoning though a poisonous dose has not actually been given. Potassium 
iodide results in iodism, manifested by coryza, laryngitis and an erythe- 
matous rash. Qtiinine gives rise to deafness, headache, nausea, subnormal 
temperature and shivering. Sodium salicylate causes hissing and ringing 
noises in the ears, headache, deafness, nausea and malaise, and an erythe- 
matous rash. 

The cumulative effect of a drug has also to be considered, and this 
means that drugs can and should oidy be given at the rate at which they 
will be absorbed, produce their effect, and then be excreted. It is import- 
ant to remember that some drugs take longer to be excreted by the kidneys 
than others, and this is why some medicines are ordered every 4 hours, 
some every 6 hours or four times a day, and others three times a day. 

Some drugs are known to tend to accumulate in the body and therefore 
more definite precautions are taken to prevent this. Digitalis, for example, 
is given only every 6 hours, and arsenic is another drug which will accumu- 
late. If this fact is ignored, untoward symptoms may develop. In the case of 
digitedis probably a powerful action of the drug would occur at first, the 
pulse becoming slow and the urine more plentiful; later, if these symp- 
toms are not reported and means taken to prevent further accumulation, 
the pulse would become irregular in character, the urine suppressed and, 
as the patient gradually became poisoned by digitalis, nausea and vomiting 
would develop. The cumulative action of arsenic would give rise to symptoms 
of disorder of the alimentary tract, including nausea, vomiting and diar- 
rhoea; and later, as the symptoms became intensified, the patient would be 
markedly dehydrated as the result of a continual loss of fluid, and if the 
administration of the drug is not omitted neuritis will develop, followed 
by paralysis of the muscles that control the wrist and ankle. 

Increased tolerance. Some persons develop ap increased tolerance 
for a drug, when repeated doses— even quite small doses — are taken over a 
fairly considerable time. They then need an increasingly large quantity 
of the drug before it will produce any effect. This is a very dangerous factor 
especially as this tolerance to the drug invariably develops in the case of 
hypnotics and narcotics — such for example as morphia, leading to the 
desire for it, and resulting in an addiction to its use. For example, a mor- 
phia addict may require to take up to 5 grains of morphia as his bres^ast 
before he can even face the beginning of his day’s work, following this by 
similar doses once or twice throughout the day until by night time he has 
had from 15 to 18 grains of the drug. 



294 


ADMINISTRATION OF MBDICINB8 AND DRUGS 


WEIGHTS AND MEASURES 
Imperial System. 

Weights (Avoirdupois) 

Unit of weight— I grain (gr.) 

I grain (gr.^ the unit of weight 
I ounce (oz.) contains 437I grains 
I pound ^b.) contains 16 ounces 

Capacity (Imperial fluid measure) 

Unit of measure — i minim (min. or m.) 

I minim (min.) the unit of measure 

I drachm, (fl. dr.) contains 60 minims 

I ounce (fl. oz.) contains 8 drachms 

1 pint (pt.) contains 20 fluid ounces 

Relation of capacity to mass in the Imperial measures. The measures of mass 
and capacity arc not quite the same. One minim weighs less than one 
grain — ^it takes 109 and a fraction minims to equal in weight 100 grains; 
and therefore it is taken that no minims equal in weight 100 mins, 
and whereas one part in 100 parts ordinarily make a i per cent, solution, 
it has to be taken that in the Imperial system i grain in no minims of 
water equals a i per cent, solution. For example the British Pharmacopoeia 
preparation of morphia for hypodermic use is a 2jpcrcent. solution; mean- 
ing that aj grains of morphia are contained in no minims of water. If 
therefore a nurse is asked to prepare J of a grain of morphia for injection 
into a patient she must remember this — as 2j contains 10 fourths of the 
whole, if she divides 1 10 by 10, this equals 1 1 minims, and J of a grain 
will be contained in that quantity. 

Metric System. 

Weights 

Unit of weight — i gramme (gm.) 

I milligramme (mg.) 0*001 gramme 
I centigramme ((^.) 0*01 „ 

I decigramme (dg.) 0*1 „ 

I gramme (gm*) the unit of weight 

I dekagramme (Dg.) 10*0 grammes 

I hectogramme (Hg.) 100 0 „ 

I kilogramme (Kg.) i,ooo*o „ 

Measures 

Unit of measure — i cubic centimetre (c.c.) or 
I millilitre (mil.) 

I centilitre (d.) 10 c.c. 

i decilitre (dl.) 100 c.c. 

I litre ( 1 .) 1,000 C.C. 

The unit of weight — the gramme — equals the weight of 1 cubic centi- 
metre volume of wato*. Because of the relatioiiship between the units of 
weight and measure in the metric systisn, dispensing is made easier. 



WEIGHTS AND MEASURES 


295 


Some equivalents of British to Metrical System. 


17 mininis = 

I drachm = 

I ounce = 

1 pint = 

35 fluid ounces = 

2 pounds 3 ounces = 


I cubic centimetre. 
4‘0 grammes. 

30-0 

568 cubic centimetres. 
I litre. 

I kilogramme. 


MODES OF PREPARATION IN WHICH DRUGS ARE PUT UP 

Aceta. Solutions in acetic acid. Examples arc : aceta scillae, which is used 
as a stimulant expectorant. 

Aquae. Solutions in water, which are usually preparations of volatile 
substances, such as chloroform and peppermint. The dose is from 
I to 4 drachms, and these solutions are used as flavouring. 

Bougies. Small rods of oily substance, prepared with glycerine and 
gelatine, containing drugs used for insertion into the ear, nose and 
urethra. The bougie is slightly heated in a little oil or warm water, 
and then inserted into the canal where it dissolves, so that the drug 
contained in it comes into contact with the walls of the orifice. 

Confectiones. Pastes of the consistency of thick jam, made of sugary 
preparations containing a drug. Amongst the best examples are 
confection of senna and confection of sulphur, both of which are 
used as laxatives, the dose being fi-om i to 2 drachms. 

Collodia (Collodions). These arc solutions of pyroxin dissolved in ether 
or alcohol, and should be kept in closely sealed bottles. Several 
varieties of collodion are described. Simple collodion is used to seal 
small punctures. Flexile collodion is a form containing some oily sub- 
stance such as castor oil, it is used to paint over irregular surfaces 
because by reason of its oily nature it works its way into crevices 
and cracks and it is used in such situations to retain dressings in 
position. Collodion vesicans is a preparation of collodion containing 
cantharides, which is a blistering agent. 

Cataplasmata. Soft moist plasters of various kinds commonly called 
poultices, which are applied locally as applications of heat, and in 
some cases contain a drug. 

Cachets. Little wafer paper boxes used for the administration of insoluble 
or nauseating drugs. Examples are quinine, aspirin and guiacol 
carbonate. 

Capsules. Flexible gelatine containers, which hold from 5 to 30 minims. 
The tiny ones are round and the larger ones egg shaped. They are 
filled through a minute hole at one end which is afterwards sealed 
by collodion, and are used for the administration of unpleasant 
tasting drugs of a liquid character, including fish-liver oil, castor oil, 
creosote, cascara sagrada and paraldehyde. 

Cigarettes. A cigarette in which a drug replaces tobacco, the commonest 
example being the stramonium cigarettes which patients smoke, 
in haling the fumes for the relief of asthma. 



296 ADMINISTRATION OF MEDICINES AND DRUGS 

Gollunarium. A nosewash. 

Goll3rrium. An eyewash. 

Decocta. Liquid preparations made by boiling solid substances in water 
for from 10 to 20 minutes, with the result that the active principle 
of the substance used passes into the water. Example — decoctum 
aloes, dose J to i drachm. 

Emplastra. Substances used as plasters by smearing on holland or silk 
with a heated spatula. Examples are lead (plumbi) plaster and 
belladonna plaster. When ordered the size of the plaster is specified 
and also the length of time it is to be kept on. 

Emulsiones. Mixtures of oil or fat and water, which arc usually rendered 
more permanent by the addition of a gum or alkali. Examples in- 
clude paraffin, and cod-liver oil emulsion. 

Enemata. Fluid preparations for injection into the lower bowel. 

Essentiae. Essences arc solutions of volatile oils in alcohol. An example is 
essence of peppermint. The dose of an essence is small, usually a 
few drops, on sugar. 

Extracta. Extracts may be solid or fluid, the former arc prepared by 
evaporating the expressed juice of plants. Examples — extract, cas- 
carae sagradae, 2 to 8 grains, and extract, colchicum, grains | to i . 

Fluid extracts are prepared by extracting a substance in a liquid. 
The liquid is then partially evaporated to make a stronger solution 
of the drug. Examples are liquorice extract (ext. glycyrrhizac. liq.) 
prepared in water, and extract of nux vomica prepared in alcohol. 

Fomenta. Fomentations are wrung out of hot water to which drugs may 
or may not have been added. 

Gargarisma. Gargles are liquid preparations for application to the 
mouth, fauces and throat. 

Glycerines. These are substances in which glycerine is used as a solvent. 
Examples are glycerine of borax, used in cleaning the mouth; gly- 
cerine ofichthyol, used as a local preparation for the relief of inflam- 
mation; and glycerine of belladonna, used for the relief of pain. 

Granules. Little pills. Example — Nativellc’s granules of digitalin, dose 
I /400th to i/6oth of a grain. 

Guttae. Dropis for instillation into the eye. 

Hauatua. A haustus is a single draught, the dose usually being large, as 
much as from x to 2 ounces. Example — ^haustus sennae co., which 
contains, in addition to senna, magnesium sulphate and liquorice. 

Infuaa. Infusions arc made by pouring either hot or cold water on a dry 
substance in a vessel, and allowing it to stand for a variable time. 
The tea we drink is an example m infusion. 

Infusion d* senna, which is made by soaking a number of senna 
pods in cold water for several hours, is a welldcnown laxative. 



MODB8 OF PREPARATION 397 

Other infusions include infusion of digitalis and infusio gentianae 
CO. The dose of each of these is ^ to i drachm. 

Injectlones. These are concentrated preparations of solutions of special 
drugs used for hypodermic injection. Examples are injcctio mor- 
phinae hypodermica, and injectio apwmorpWnae hypodermica. 

Inhalationes. Inhalations are administrations of volatile substances in 
water in which the vapour of the water is inhaled (see p. 247) . 

Insufflationes. Spraying with powders, usually on to the walls of cavities, 
such as the phar^mx and nose. 

Lamellae. Small thin disks made with gelatine or glycerine used to drop 
into the eye. Examples are atropine and eserine disks. ‘ 

Linctus. Substances of a sticky nature used as a sedative when a cough 
is irritable and ineffective. They contain a basis of syrup and gly- 
cerine, and in some cases sedative drugs are added, a linctus 
accordingly being described as a simple or an opiate linctus. 

Linlmenta. External applications of soapy and oily preparations used as 
counterirritants or as sedatives or antispasmodics for the relief of 
pain according to the ingredients contained in them. Many of these 
contain alcohol, chloroform, belladonna, turpentine or menthol. In 
• applying a liniment it is important to rub it in warm, and to con- 
tinue rubbing until the skin is well reddened. 

Liquores. Solutions of special drugs, in many cases of very potent ones, 
in water. In the following instance the solution contains i grain of 
the drug in no minims of water, making a i per cent, solution (sec 
page 294). Liquor morphinae hydrochloridi; dose 5-30 minims. 

Lotiones. Watery mixtures for external use. Examples are lotio rubra 
which contains zinc, lavender water and a colouring preparation, 
and lotio nigra, or blackwash, which is a mercurial preparation. 

Mella (Honey). Example — mella boracis, which is used for cleaning tlic 
mouth when glycerine of borax is found to be too astringent. 

Mistarae. Mixtures are solutions of substances suspended in water or 
mucilage. Most of the medicines commonly prescribed are mixtures. 

Nebulae. Oily or aqueous preparations sprayed on to areas by means of 
an atomizer. 

Olea. Oils. Examples include oil of cloves, oil of tiupentinc and oil of 
cajuput. 

Pastes. A preparation similar to ointment but containing powder (see 
Lassar’s paste, p. 503). 

Perles. Little gelatine capsules (see also Capsules). 

Pessarla. Solid conical substances, similar in shape to suppositories, made 
up with cocoa butter, and used for insertion into the vagina in order 
to bring a drug into contact with the vaginal wall, 

Pidntentum. A preparation in tlic form of a tacky paint for local applica- 
tion. Example — pigmentum Mandl, used as a throat paint. 



298 ADMINISTRATION OF MEDICINES AND DRUGS 

PiUulae. Pills containing a drug, and usually coated with sugar or silver. 

Pulveres. Powders. Examples — Gregory’s, Dover’s, pulv. jalapae co. 

Solutiones. Watery preparations containing a dissolved solid substance, 
such as for example a saline solution, and solutions of glucose and 
sodium bicarbonate. 

Those containing a more powerful drug are frequently made up 
in a uniform strength of i, 2 or 4 per cent. Examples include prepa- 
rations of cocaine. 

Suppositoria. Cone-shaped substances for rectal administration, usually 
prepared with a basis of gelatine, or oil of theobroma. One example 
is the glycerine suppository, which is used to evacuate the rectum. 
Other examples include belladonna and opium suppositories. 

The pessaries used for vaginal administration are sometimes 
described as suppositories. 

Syrupi. Sugary liquid preparations used for flavouring medicines. An 
example is syrupus lemonis. 

Tabellae (Tablets). Nitroglycerine prepared with chocolate — trinitrin. 

Tincturae (Tinctures). Solutions of the active principle of the drug in 
alcohol. Examples are tincture of digitalis, tincture of opium, the 
dose of either l^ing from 5 to 15 minims; tincture of strophanthus, 
dose 2 to 8 minims; tincture of belladonna, dose 15 to 20 minims. 

Tinctures are prepared in alcohol which is scarce at present and 
in many cases an ^temative, authorized under the ‘Shortage of 
Drugs’ order, must now be employed. Most of the authorized alter- 
natives are liquid preparations in water which have the same 
therapeutic value as the tinctures formerly used. 

Trochisci (Lozenges). These are usually made with a fruit basis, and 
may contain a sedative, astringent or antiseptic agent. 

Unguenta. Ointments arc semi-solid preparations of a fatty suj^tance 
containing an active drug, and intended for external use. 

* Vina. Liquid preparations in which sherry is used as a solvent. Examples 
— vinum antimoniale, dose 10 to 30 minims; vinum ipecacuanha. 
(The 1932 edition of the British Pharmacopoeia altered the name 
of this latter preparation to tincture of ipecacuanha.) 

Vaporea. Preparations by which the inhalation of volatile drugs is ren- 
dered possible, when exposed to the air. 


CLASSIFICATION OF DRUGS WITH EXAMPLES 

Anaesthetics are drugs which produce loss of sensation when applied 
locally, and loss of consciousness when a general administration is made 
(see also p. 627). 

Anthelmintics are drugs used in the treatment of worms or intestinal 
parasites. There arc three tinds of worms which chiefly infest the alimen- 
tary tract in man— tapeworm, roundworm and threadworm and, less 
frequently, the hookworm (for symptoms and treatment sec p. 388). 

* S«e note on Ttoetures above. 



OLAaamoATioN of druos 299 

Male fern (filix mas) is used in the treatment of tapeworm in the form 
of extract of male fern. It is nauseating and is theretore frequently given 
in cj^sule form, the dose being from 45 to 90 minims. 

Santordn is the drug which is specifically used in the treatment of round- 
worm and in some cases in the treatment of threadworm. The dose is from 
I to 3 grains. Santonin may render the urine yellow in colour and may 
also cause the patient to ‘see yeUow’ (yellow vision). 

Thymoly from 15 to 30 grains is used in the treatment of hookworm. 

Irifusion of quassia i per cent, is given as an enema in an attempt to clear 
the lower bowel of threadworm. 

Antidotes are drugs used to produce an opposite effect in order to com- 
bat symptoms of poisoning, as for example where atropine is administered 
in cases of morphia or opium poisoning. 

Antipyretics are drugs which lower the temperature of the body. These 
are rarely used for this purpose today, though they arc employed when, in 
addition to lowering the temperature, they have a specific effect in the 
treatment of certain diseases. 

Examples are quinine sulphate or quinine hydrochloride, used in doses 
of from I to 10 grains in the treatment of malaria; salicylic acid, dose 5 
to 10 grains which is specific in rheumatism; aspirin, antipyrin and anti- 
fcbrin — dosage 5 to 10 grains — are used as analgesics for the relief of 
neuralgia and myalgia, and also as diaphoretics to reduce temperature. 

Antiseptics are substances used to prevent the growth of organisms 
when applied externally. Therapeutically, antiseptic substances are used 
to produce some effect on one or other of the systems of the body, but they 
must of necessity be given in very weak solutions, otherwise their action 
would be injurious to the tissues. 

Examples include — respiratory antiseptics — creosote, minims 1-3; salivary 
antiseptic — ^such as p>otassium chlorate; intestinal antiseptic — such as guiacol 
carbonate, dose 5-10 grains; hexamin, dose 15-30 grains, acts as a 
urinary antiseptic and also as a biliary antiseptic. 

Antitoxins. These are substances opposed to the action of toxins in the 
blood, and are administered in the form of antitoxin serum. The dose 
varies according to the disease for which it is used. Scarlet fever antitoxin 
is administered in doses of 10-20 c.c. Diphtheria antitoxin and tetanus 
antitoxin arc prepared in units — the dose vauying from 3,000 units up- 
wards. (See also p. 325.) 

Astringents are substances which lessen secretion by causing contrac- 
tion of the lumen of the blood vessels in the walls of the tissue to which 
they are applied. 

Examples m these include tannic acid, which is contained in many of 
the throat paints, and also given in the form of an enema in the treatment 
of some forms of diarrhoea. An example of an astringent, given hypo- 
dennicaUy to produce its effect on an organ for whi<^ it is specific in 
action, is ergot, the dose of extract of ergot being from 30 to 60 minims. 
It acts by stimulating contraction of the blood vessels in the uterus and 
arresting haemorrhage. 

Cardiac Drugs. See Stimulants, also see p. 352. 

Carminatives. These are substances which result in expulsion of flatus 
or gas, from some part of the alimentary tract, either upper- or lower. 



300 ADMINISTRATION OP MEDICINES AND DRUGS 

They act by stimulating contraction of the involuntary muscle contained 
in the walls of the canal. They are usually ordered to be given occasionally 
or as required. Examples of those administered by mouth include oil of caju- 
put and oil of peppermint, dose 1-3 minims. These may be administered 
on a lump of sugar. Other examples include cloves, ginger, dill water and 
sal volatile. 

Carminatives which may be administered by the rectum include tur- 
pentine, and asafoetida (see also Enemata). 

Cholagogues (see Purgatives). 

Diaphoretics are substances which increase the action of the skin and 
are therefore used in the treatment of febrile conditions when the skin is 
hot and dry, and also in the treatment of chronic nephritis, with oedema, 
in order to assist the elimination of water from the body by causing the 
skin to act. A similar effect can be produced by a local application of heat 
to the skin (see also p. in). Examples of diaphoretics are pilocarpine nitrate 
— dose from i/20th to i/5th grain — ^which acts very quickly, so that the 
patient should be prepared for sweating by wrapping him in blankets, 
surrounded by hot water bottles before the drug, which is given hypoder- 
mically, is administered; sweet spirits of nitre (spirit of nitrous ether), 
15 to minims; and liquor ammonium acetate, 2 to 8 drachms. 

Diuretics. These drugs increase urinary output, by stimulating the 
function of the kidney. Only very mild alkaline substances such as potas- 
sium citrate can ever be used as diuretics in the treatment of acute 
nephritis. All drinks are diuretic, including tea. Other articles of diet, 
which are diuretic in action, include theobromin in cliocolate, and caffeine 
in coffee. 

Examples are potassium citrate, potassium acetate and potassium 
tartrate, dosage 15-60 grains; liquor ammonium acetate, 2-8 drachms; 
liquor ammonium citrate, 2-6 drachms; infusion of buchu, l-2 drachms. 
Urea, dose from 15 to 240 grains, is also used as a diuretic. 

Merciay is a powerful diiuctic. It is used in the form of Mersalyl in 
doses of 8 to 30 minims. One dose may result in the output of seven to 
eight pints of urine. The use of mercurial diuretics in the relief of cardiac 
o^ema is described on p. 281. 

Guy’s pill which contains three important diuretic drugs, mercury, 
squills and digitalis is another method of giving mercury. 

Emetics. These substances produce vomiting, cither by irritating the 
mucous membrane of the stomach or by stimulating the vomiting centre 
in the medulla. Examples of the former t)^ include mustard, i tablc- 
spoonfiil to a tumbler of water; or salt, 2 tablespoonfuls; and tartar emetic, 
2-4 drachms. Examples of the latter type include tincture of ipecacuanha, 
which is given in fairly large doses of 10 to 30 minims^ and apomorphine 
hydrochloride, dose from i /20th to 1 /6th of a gram, ^ven hypoder- 
mically. This is used when it is necessary to induce vonuting in uncon- 
scious patients. 

Expectorants. As a rule expectorants increase the amount of secretion 
from the lungs, and in this case they are described as stimulating ex- 
pectorants. These are used when cough and sputum are present as in the 
later stages of bronchitis. Examples of stimulating expectorants are am* 



GLASSinaATION OF DRUOS 30I 

monium carbonate, 5-10 grains; ammonium chloride, 5-60 grains; 
infusio senegae co., \-i drachm; syrup of Tolu, J-i drachm; tincture of 
scillae, 5-30 minims. 

Potassium iodide, dose from 10 to 30 grains, and sodium bicarbonate, 
dose from 10 to 60 grains, are frequently included in stimulating expec- 
torant mixtures, as they dissolve mucus and render expectoration easier. 

Another group of drugs which increases the amount of expectoration 
by its stimulating action on the respiratory centre, is nux vomica, and its 
active principle, strychnine. 

Depressant expectorants are used when a cough is ineffectual and painful, 
and serves no useful purpose, and therefore is better inhibited. Examples 
include any soothing syrupy preparation in the form of a simple linctus 
which may contain glycerine, and one or two fruit syrups, such as syrup 
of prunes and lemons. More pjowerful ones contain an opiate, either 
heroin, opium or morphine. 

A linctus is usually given in doses of from i to 2 drachms, and it should 
be sipped slowly from a warmed teaspoon. 

Hypnotics and narcotics. Hypnotics are substances which induce 
sleep and have little or no effect on pain, whilst the stronger hypnotic 
or narcotic will relieve pain and by so doing induce sleep. Examples of mild 
hypnotics which are of no use at all for the relief of pain include potassium 
bromide, ammonium bromide and sodium bromide, dosage from 15 to 
30 grains. Scdabrol is a proprietary preparation of bromide containing 
17 grains of the drug in each tablet; the tablets are brown, and when 
dissolved taste like meat juice and are quite pleasant to drink. One or two 
tablets dissolved in hot water are usually given at bedtime. 

Stronger hypnotics are drugs which are liable to be poisonous in their 
effects if taken in too large quantities. These include luminal — dose from 
i to 5 grains — which is used very largely in the treatment of epilepsy, 
bennning with J grain twice a day, and increasing as required. Others 
indude medinal, 1-5 grains, and a stronger drug is dial, I-5 grains, and 
di-dial which contains a little morphia, J grains. Dover’s powder, or 
pulv. ipecacuanha and opium, dose from 5 to 10 grains, is frequendy 
used as a sedative in the early stages of pneumonia and influenza. Chloral 
hydrate, dose 10-20 grains, is apt to be depressing to the heart; this drug 
is frequendy combined with bromide. Chloretone, dose 10-20 grains, 
is used as a sedative in chorea, and in some forms of cramp. 

More powerful drugs of the same class, which because of their value in 
relieving pain arc dassed as narcotics, are morphia, grain i/8th to i/3rd; 
heroin, grain i/25th to i/8th; and hyoscinc, grain 1 /200th to i/iooth. 
The latter drug is frequently used in cases of delirium tremens. 

Laxatives (see Purgadves). 

Mydrlatics are drugs used to dilate the pupil of the eye. 

Examples are atropine and homatropine, in | to 2 per cent, solutions, 
atropine being insdUed as often as necessary to produce, and maintain, 
the desired effect. 

Myotlcs are substances which cause contraction of the pupil of the eye 
and indude eserinc and pilocarpine, instilled as above. (Opium causes 
contraction of the pupil of the eye, which is one of the earliest signs of the 
overdose of this drug, but it is not used as a myodc.) 



302 ADMINISTRATION OF MEDICINES AND DRUOS 

Purgatives. Aperient drugs are usually given by mouth. In a few 
instances rectal achninistration is made (see Bnemata). The hypodermic 
administration of pituitrin — dose from 5 to lo units — which acts as a 
stimulant to peristalsis, is used in the treatment of paralytic ileus (see 
P- 639). 

Purgatives are classified, according to the severity of their action, into 
laxalioes, simple purgatives, and drastic purgatives or cathartics. They 
arc furAer dassified according to the manner in which their effect is 
produced, as lubricants, such as liquid paraffin, dose 1-8 drachms; 
hydragogues, which extract water from the blood, such as concentrated 
doses of magnesium sulphate; and cholagogues, which stimulate the gall- 
bladder to empty itself and ^o stimulate the liver in its production of 
bile. Examples include salines, mercury and aloes. Other substances act 
as aperients because they increase the food residue and therefore add to 
the bulk of the contents of the intestine — among food substances producing 
this effect are fhiits, green vegetables and wholemeal bread. 

The action of the bowel may also be affected by drugs acting on the 
neuromuscular mechanism. In spastic constipation belladonna is admin- 
istered, and by its antispasmodic action effects relaxation of the contracted 
gut and so relieves the constipation resulting from this. 

Conversely, when the walls of the bowel are relaxed and lacking in 
tone, or dilated, the administration of small doses of strychnine or nux 
vomica will increase the tone and stimulate contraction of the muscle in 
the walls of the gut. 

Examples of laxatives. Syrup of figs, 1-4 drachms; confection of senna, 
1-2 drachms; liquid magnesia, 1-2 ounces; pulv. glycyrrhizae co., which 
contains sulphur, senna and liquorice root, is given in doses of 1-2 drachms. 

Simple purgatives include aloes, in the form ofpil. aloes, 4- 8 grains, extract 
of aloes 2-8 grains. Cascara is given as extract of cascara sagrada, 2-8 
grains. In tablet form, and liquid extract of cascara, dose J-i drachm. 
This form is bitter and very often objected to by patients, and is therefore 
usually given in capsules. A proprietary drug, which is quite pleasant to 
take, is cascara cvacuant, dose ^-t drachm. Gregory’s powder contains 
rhubarb and m^nesia. Phcnolphthalein, i to 5 grains, is usually com- 
bined with paraiim. 

Salines remove a good deal of water from the bowel. Magnesium sul- 
phate and sodium sulphate are given in doses of J to 2 drachms dissolved 
in water. 

Seidlitz powders arc an example of a saline aperient. These arc 
prepared in two packets. A blue packet which contains sodium bicar- 
bonate and sodium potassium tartrate and a white packet containing 
tartaric acid. The contents of the blue packet arc dissolved in half a 
tumbler of water, the contents of the white packet are added, the mixture 
is briskly stirred and the fluid is drunk whilst in effervescence. 

Drastic purgatives. Calomel i to 3 ^ains. Calomel may be given as a 
single dose of one, two, or three grams. Or it may be given in J grain 
or I grain doses, until a maximum of i to 3 grains has been given. Calomel 
should always be freshly obtained as it becomes altered and converted 
into perchloride of mercury when kept. As a general rule calomel is either 
combined with another purgative or followed by a salim aperient in order 
to prevent the drug accumulating in the system. 

Pulv. scammony co., 10 to 20 grains, and pulv. jalapae co., 10 to 



CLASSmCATlON 07 DRUGS 303 

60 grains, are used when it is desirable to obtain a watery action of the 
bowd, as, for example, when oedema b present. Pulv. jalapae co. contains 
jalap, ginger and cream of tartar. 

Pil. colocynth, a to 4 grains, is a very strong aperient. It is frequently 
combined with hyoscyamus which is an antispasmodic and prevents pain 
being produced by the griping action of the colocynth. Hyoscyamus 
bdongs to the belladonna group of drugs and therefore this subkance 
should not be used as an aperient for patients suffering from glaucoma. 

Castor oil when given in large doses, of from i to i ounce, is a strong 
purgative. Groton oil, in doses of from ^ to i minim, is prescribed in 
apoplexy and cerebral compression when a very rapid action of the bowel 
is desir^. 

Styptics. Any drugs used to arrest bleeding by local application are 
described as styptics. An example may be found in the use of adrenalin 
1-1,000 for packing the nasal cavity before an operation. Tincture of ferri. 
perchloridc is another example. Most astringent substances are styptic in 
action. 

Stimulants. Stimulants usually act either by means of the circulation 
or through the central nervous system, by stimulating the different special 
centres and so producing an effect on the function of some particular 
organ. For example, apomorphine stimulates the vomiting centre in tlie 
m^uUa and makes the patient sick. Some of the expectorant drugs 
produce their effect by stimulating the respiratory centre. Strychnine is a 
stimulant to the general circulation. Caffeine, coraminc and camphor are 
cardiac stimulants. 

Speaking more generally the term stimulant is used to imply the 
administration of some form of alcohol. In hospital practice, brandy is most 
commonly used. The dose for infants is from a few minims up to ^ drachm. 
The adult dose is from | to i ounce at a time, not more as a rule than 2-3 
ounces being given in ^e 24 hours. Brandy should never be given at the 
same time as other medicines, and it should always be diluted — one part 
of brandy to two parts of water. Port wine is a stimulant sometimes given 
to convalescent patients as an aid to improving their appetite. As a rule 
two to three ounces are given each day with meals. Champagne is an 
expensive form of alcohol. It is given in small doses fiequendy to patients 
who are very ill and who for some reason are incapable of taking or re- 
taining other forms of liquid. 

Alcohol acts as a general stimulant to the circulation and so increases 
for the moment the sense of wellbeing. Because of its rapid effect it is, 
therefore, a very valuable cardiac sdmultmt in emergencies such as 
fainting and syncope. The exhilarating effect of alcohol, however, is 
followed by depression of the central nervous system. 

Stomachics are drugs used to stimulate the activity of the stomach, 
one group being describixl as bitters, which stimulates the flow of saliva 
and gastnc juice. They are bitter to taste as the name implies and include 
infunon of calumba co., infiisio gentianae co., and infusio tincturae 
aurantii. The dose of each is from 30 to 60 minims. They are used in many 
tonic preparations and are gastric tonics. 

Stomachic substances may also act by increasing the movements of the 
stomach. Tincture of nux vomica, dose from to to 30 minims, is an ex- 
ample of this type. 



304 ADMINISTRATION OF MEDICINES AND DRUGS 

The function of the stomach is improved in cases of achlorhydria by the 
addition of dilute hydrochloric acid, dose from 5 to 60 miniros. This drug 
is given with orange juice and taken during, and about 10 minutes ailer, 
fo<^. 

Tonic drugs are used to improve the tone of the general health. 
For example (see Stomachics), gastric tonics such as gentian may be used 
to stimulate the appetite, thus resulting in increase in weight and general 
physical improvement 

Other tonic substances such as iron act by improving the quality of the 
blood, which may be given in the form ofBlaud’s pill, from i to 5 grains; 
or it may be combined with another drug, as in ferri et ammonii citrate, 
dose from 5 to 1 5 grains, or in a mixture, such as Parrish’s chemical food, 
which contains iron, phosphates and c^cium among other ingredients. 
The dose is from 30 to 120 minims. Sometimes iron is administered with 
arsenic, which is a nerve stimulant, thus combining two forms of tonic 
substance in one mixture. 

Preparations of iron should always be carefully dealt with, as iron stains 
the teeth. When liquid preparations are us^, they should be g^ven 
through a straw, and the teeth should be well brushed afterwards. 

Strychnine is a general tonic to the circulatory system as well as a 
respiratory stimulant, and it is contained in many tonic mixtures and 
preparations. Easton’s syrup is one example, containing i /60th of a grain 
of strychnine in each drachm. In addition it contains iron, which is a 
blood tonic, and quinine which acts as a nerve and gastric tonic. 


UNDERSTANDING A PRESCRIPTION 

The word prescription is derived from prae meaning ‘before’, and 
scribo, I write. It is the usual manner in which drugs are ordered and, 
contains instructions from the doctor to the dispienser as to the ingredients 
to be used, and the manner in which the medicine is to be administered. 

It is usually written in Latin, partly because this is a universal language 
and therefore the prescription written in it can be dispensed in most 
civilized countries, and partly because the majority of patients cannot 
read Latin and some physicians think that it would not be good for a 
patient to know exactly what drug he is having. 

A prescription is divided into five parts: 

{ I ) The heading, which indicates the name of the patient. Beneath this 
in the left-hand corner is written R meaning recipe, or ‘ take thou’. 

(2) Names of the substances prescribed come next. Each occupies a separate 
line, and is followed by the symbol of the weight and measure to be used 
and the amount to be included in the mixture. 

(3) The instructions to the dispenser as to how the medicine is to be pre- 
pared, as to whether it is to be a liquid, pill, powder, &c. 

(4) Directions as to mode of administration This also may be in LaUn for the 
instruction of the dispenser, but it is also written clearly in English on the 
label for the use of the nurse and patient. 

(5) Lastly, at the bottom right-hand comer, the doctor writes his 
initials or signature, and in most cases adds the date. 

For special precautions taken in the writing prescriptions containing 
dangerous drugs, see note on p. 332. 






Fic;. paiic 314. On a iray for giving medicines provide 

water to dilate the medicines, bowl of water and glass cloth 
for washing and drying medicine measures. A delf oil cup or 
spoon is used for giving oil and emulsion. Straws arc required 
for medicines containing iron. 



Fk;. see (Hijic (A) llypodemiic syringe. (B) needles 

to fit syringe. (C') a small minim measure. (D) small dissecting 
forceps, spoon. In addition swabs and spirit are needed for 
c leansing the skin and some distilled water in which to dissolve 
the drug when it is put up in tablet form. 




Fifi. 1 f) 1 . -.see page 3 1 7. 

C^UAlUilNC. A HyPODKRMIC SyRINGK from a PlIlAI. 




H||ll 



Fig. 1 32.- see page 3 1 7. 
Charging a Hypodermic Syr- 
inge FROM A Rl nUER-CAPPFl) 
BoriLE. 




53 * — see page Giving a HYroDEUMic IsjEcnioN. 



i ui , 134, — see page 317. Giving an Intra* 
Mi sct LAR InJKCTION INTO THE Bui'TOCK. 
The nc<'dl(‘, hrld at right angles to the skin, 
is plunged up to ihe hilt into the muschr, 
at the upper and outer quadrant. 


309 



Fu,. if,6. vdT pa^e 310. Articles for S'^eam 
iNHALAnoN. \\) Nelson’s inhaler showinej 
the eorreet position of glass mouthpiece. 
(B) Inhaler prepared for use, in Hannel cover 
and standing in a delf porringer. The mouth- 
])icce is covered with gauze as it may be too 
hot for the patient's lips to rest on it. 

'The l)ottle on the tray contains friar’s balsam 
spoon is provided for measuring the one 
or two drachms reeptired. In some cases a 
thermometer will be needed. 





1 H,. i-)7. 322. 

... ^ IniR.WASAI. .\UMIN1STRA I111N <IF ( )xYt;KN. 

tR- nostrils should Ik- rlcai, thr cathci< r is luhricaU'd 
arid pa.ssfd hackvvarrls into ihr pharvnx. (See also Fies 
164 and ih5 on patic :y2'2.) 

Oxygen icquir<-s to pass through vvat.r in order to 
mohsten It; for this pur|H>.se a flowmeter and humidifier 
.nay be employed (tee /<,<;. 158), ur Wolffs bottle may 
be used. ' 







3*1 



I'K;. 1 f)H. sec fui^e y2 2 . 

B.L.B, iHoOTHV, I.OVKI ACK AND BiyLlU I.l AN i OXYDEN 

Inhalauon Apparatus in Use. The mask can he seen in detail 
on f)a^^e 33 ;]. 

In the illustration the oxygen is passed through a flowmeter 
and humidifi<a\ hhe use of a humidiher can lx* dispiaised 
with, as the n\sei\'oir breathing bag, being closed by a small 
glass stopper at the distal extremity, C9lle(’ted moisture as 
the patient breathes in and out of the bag. 




SAVE CUSTODY OF MEDICINES AND DRUGS 


313 


THE SAFE CUSTODY OF MEDICINES AND DRUGS 

In hospital practice all drugs are checked as they arc received from the 
dispensary. 

llie medicine cupboard is usually kept or placed in a room adjoining but 
not in the ward. 

All poisons are kept in a separate cupboard, in which difierent compartments 
or shelves may be allocated to oifferent types of poisons — ^for example, 
lotions, liniments &c., may be in one part, and the very potent drugs 
used for hypodermic injection in another part of the cupboard. As far as 
possible all poisons should always be in ^e same place, so that a nurse 
going to a cupboard in a hurry will automatically put her hand in the 
direction in which she expects to find that for which she is looking, though 
this must not be relied on. In addition, the poison cupboard should be lit 
from the inside, and failing this precaution the nurse should use a torch 
when the light is poor. Poisons are kept in bottles distinguishable to the 
touch by being ridged or grooved, and to sight by being coloured blue 
or green. A nurse should never be permitted to change the label on any 
bottle containing poison — this should only be done by the dispenser who is 
rcsfxmsible for issuing the poison in any particular bottle. 

The poison cupboard must always be kept locked — in some instances a double 
locked cupboard is used, but the important point is that the key should 
never be kept in a so-c^ed ‘ safe place’, but should always be on the 
person of the sister or head nurse in charge of the ward, who as far as 
possible will herself always handle the contents of this cupboard. A junior 
nurse should never be permitted to administer drugs to a patient. 

Certain special substances including vaccines, antitoxin sera and 
insulin, together with other drugs of animal derivation, require to be 
kept in a cool place. A trained nurse should be familiar with the customary 
dose of the drugs in constant use that may be ordered; if in doubt, she 
should verify the dose, and she may even query a dose if she considers it 
excessive in amount, though such a query should of course be made with 
tact — a nurse should never be afraid to ask questions about the dosage 
and action of drugs — the number of dangerous drugs on the market is so 
various and they are so often made up in different strengths that she need 
never be ashamed to show her ignorance on this matter and should always 
be ready to learn. 

As far as possible trained nurses should make themselves familiar with 
new drugs introduced from time to time. The action of any drug given 
to a patient should be ascertained, so that its effects can be noted, and 
any untow'ard symptoms quickly observed. 

A nurse should be very strict with regard to the checking of drugs. 
During her hospital training she will be impressed by the ritual with which 
the checking of a dangerous drug is carried out, and the meticulous pre- 
cision observed by everyone concerned, so that if she remains faithful to 
the training she has received she will not be likely to err. 

(See also the note on the administration of the Dangerous Drugs Act, 
on p. 339.) 

RULES FOR GIVING MEDICINES BY MOUTH 

Medicines must be given punctually and, as they are most readily 
absorbed on a comparatively empty stomach, they are usually given 



314 ADMINISTRATION OF MEDICINES AND DRUGS 

between meals and feedings. They are given at stated hours, such as lo, 
2 and 6; or 1 1, 3 and 7, unless the m^icine is specially required to be 
given in relation to food. 

A gastric irritant, such as arsenic or iron, is given after food. Medicines 
employed to produce a general beneficial effect on the weUbeii^ of the 
body, to produce increase of weight and improve the changes whi^ make 
up metallism are also given after food, hbcamples of such medicine are 
malt and cod-liver oil. 

Medicines given to allay spasm, such as chalk and bismuth, to inhibit 
secretion, such as belladonna, atropine and olive oil, to affect the reaction 
of the gastric juice, such as hydrochloric acid or alkalis, and bitters, 
which are given to stimulate the gastric secretion, are all given before food; 
though when alkalis are used in the treatment of peptic ulcer, with the 
object of reducing the acidity of the gastric juice fairly constantly, they 
are given after meals. 

Aperients are usually given on an empty stomach, last thing at night, 
especially when the drug employed is laxative in its effect and acts 
slowly, taking fix>m 10 to 12 hours to produce its effect. A]>erients which 
have a rapid action, such as the saline aperients, are given on a fasting 
stomach first thing in the morning, half an hour before the first drink of 
tea is taken. 

A nurse should have a good working knowledge of the time an aperient 
she may be asked to give will take to act, and she should administer the 
medicine at a time which will allow the patient to be as little disturbed 
as possible by its action later. Strong purgatives like large doses of castor 
oil and colocynth act in from 4 to 6 hours; hydragogue purgatives, like 
salines and jalap, may act within 2 hours. Drugs such as these should not 
be given at the patient’s bedtime or the result vrill be that he will be dis- 
turbed in the early morning hours. 

The articles required for giving a dose of medicine arc shown in fig. 148, p. 305. 
In some cases the patient’s bedcard will be required to verify the pre- 
scription, although in most wards the sister or head nurse checks the 
prescription written on the bottle of medicine with the original on the pre- 
scription card as soon as the medicine is received by her; a distinguishing 
mark is made by the ward sister on the bottle to show that the prescription 
has been checked. But whenever the medicine contains a dangerous drug 
the bedcard should be produced and the dose checked by a second person 
vrith the prescription on the card at each administration. 

The administration of medicines requires the greatest possible care 
and thoughtfulness, as well as undivided attention. Whilst pouring out 
and delivering medicines, a nurse should not attend to any other matter; 
there should be no general conversation or chatter; the nurse engaged in 
giving medidnes should not be spe^en to, or otherwise interrupted, except 
in a case of emergency. The directions on the medicine bottle label shoiud 
be read carefully, before and after pouring out the dose of medicine. 

Bottles containing medicine shoiud always be shaken but not by an up 
and down movement which causes froth to form on top of the fluid; 
the nurse should place one finger on the cork to prevent its flying out, 
and then shake the bottle, using a side to side, swinging pendulumlikc 
movement, inverting the bottle cornffletely once or twice during the 
process. 



RULES FOR GIVING MEDICINES BY MOUTH 315 

In pouring out a dose of medicine, the bottle should be held with the label 
uppennost, and the fluid be poured out away from the label, any drips 
being caught with a swab of cotton wool before replacing the cork. 

The marked medicine glass or measure should be held with the marks 
against the light, just above the level of the eye, so tliat the person pouring 
out the medicine has to raise her head slightly to look at the level of the 
fluid in the glass. The surface of fluid in a small measure is not flat, it has a 
curve — called the meniscus — ^which is lowest at the centre so that, if the 
measure is held just above the level of the eye, the lowest point of the curve 
of the meniscus may be considered to be on a level with the marking on 
the medicine glass. 

As far as possible medicines should be poured out at the bedside of the 
patient for whom they are intended, but in all cases the medicine should 
be delivered to the patient before any sediment can settle. The nurse 
should stand by the patient until the medicine has been swallowed, and if 
permissible a little water may be given afterwards or the mouth may be 
rinsed. In administering medicines which have an unpleasant flavour the 
mouth should always be rinsed afterwards, and peppermint water is a very 
pleasant preparation to use for this purpose. Medicines that stain the teeth 
are usually administered through a straw and the teeth brushed immedi- 
ately afterwards. 

Oily preparations may require special preparation, and in all cases if 
permissible they may be followed by a section of orange given to suck. In 
administering castor oil, for example, it should be disguised in some such 
way as the following. Take an oil measure, which is made of delf or earth- 
enware, and warm it. Pour in some orange or lemon juice and^float the 
dose of castor oil on to this, cover with more fruit juice, taking care not to 
shake or move the measure about, so that the oil is kept floating inside a 
covering of fruit juice. In taking it to the patient advise him to open his 
mouth and pour it quickly to the back of it and swallow at once in order 
to avoid movement of the fluid which would result in his tasting the castor 
oil. Giving a little bread to chew, or bread and salt, after the administration 
of any unpleasant form of oil, tends to relieve the mouth of the nauseating 
slimincss. If the patient is not allowed solid food he may spit out the bread, 
or alternatively he might rinse out his mouth with peppermint water. 

In giving tablets, pills, cachets and capsules, they should be delivered in a 
spoon and accompanied by a large glass of water. Cachets may be softened 
by placing them in a spoonful of water before swallowing. Powders should 
be unfolded, collected to the middle of the packet and poured on to the 
centre of the protruded tongue. The patient should be given water 
sufficient to swallow the powder. If he objects to this mode of admin- 
istration, the powder may be buried in a spoonful of jelly or jam, provided 
these form part of the patient’s diet. 

Effervescing powders should be dissolved in half a tumbler of water and 
drunk whilst effervescing. 

Pills. Some patients find it extremely difficult to swallow pills, and the 
nurse should, m such cases, be very patient and try various means — the 
pill may be buried in jelly or jam, or in a piece of bread, if the patient is 
allowed these. It may, however, have to be crushed and given as a powder. 

Giving naedlcin* to children. As far as possible the medicine should 
be made pleasant to taste. The nurse may have to be firm, but force 



3i6 administration of medicines and drugs 

should never be used. A child can usually be persuaded to swallow his 
dose of medicine by having a sweet, a nice driidc or a little fruit or other 
similar treat after it. In some children’s wards it is usual practice to give 
the daily ration of fruit in small pieces at medicine times. A tiny child 
should have his cheeks gently held together by the nurse, and the medicine 
administered by means of a spoon; if the child cries he will only breathe 
through the medicine, thus gargling with it for a few seconds and, when he 
stops to breathe in, he will swallow the dose. 

MODES OF ADMINISTERING DRUGS 

By wc^ of the alimenlaty canal, either by mouth, which is by far the 
commonest route used, or by means of the rectum. All drugs taken by 
mouth are passed to the liver in the portal circulation and excreted in 
lai^e quantities by the kidneys without remaining long in the circulation. 

By hypodermic or subcutaneous injection. By this route drugs enter the 
circulation through absorption by means of the lymphatics, and many 
drugs, that would be injuriously affected by the digestive juices if given 
by mouth, are administered in this way, including adrenalm, insulin and 
some forms of liver extract. 

By intramuscular injection. By this route more rapid action is made 
possible, and many of the preparations of drugs suspended in oil and pre- 
parations of quinine arc admnistcred thus. 

IntraUucally, or by means of the cerebrospinal fluid route, and this 
method is chosen in the treatment of some forms of meningitis (for mode 
of administration, see lumbar puncture, p. 206). 

IntraperitoTual route. This method is most commonly adopted for the 
administration of saline and, more recently, sera have been given in this 
way with excellent results and with less danger of complications than 
when given by the intravenous method. 

Intravenous method (for mode of administration, see pp. 197 and 381). 

By the skin by inunction and ionization (see p. 324). 

By inhalation (see also p. 319). 

By subcutaneous or hypodermic administration or injection. 
By this means drugs reach the blood stream more rapidly than when 
given by mouth. It is also employed in many instances where the drug 
does not remain potent when it is administerol by the mouth, owing to 
the affecting of its action by the digestive juices. 

The apparatus required is a hypodermic needle, which should be sharp, 
and a syringe capable of holding 15-20 minims. Some swabs and possibly 
some mild antiseptic, or alcohol, should be provided to cleanse the skin. 
Sec figs. 149 and 151-4, pp. 305-8. 

Method of administration. There seems to be a considerable amount 
of uncertainty amongst nurses as to whether the drugs which are put up 
in solid form, in tablets or tabloids, may or may not be boiled in a tea- 
spoon over a spirit lamp in preparation for administration. 

The following stdutions may be sterilized by boiling without being 
injuriously affected — Mo^hine hydrochloride, pilocarpine nitrate and 
s^chnine sulphate; but in the case of such drags at the fdlowing, the 
distilled water should be boiled first to render it sterile and then almwed 



MODES OV ADMINISTERING DRUGS 


3»7 

to cool to about ioo“ F. before adding the hypodermic tablet — Apo- 
moiphine hydrodiloiide, atropine sulphate, digitalin, eserin, emetine 
hydrochloride — horoin hydrocmoride, (diamorphine) — hyoscinc hydro- 
bromide — ^morphine and atropine — ^morphine, atropine, and strychinc — 
moiphine and hyoscine— strophanthin. 

Charging a y/ringe. There arc different methods of handling the tablet, 
but it i^ould not be touched by fingers since inflammation may occur at 
the site of injection if aseptic technique is not observed. Some sisters keep 
a small sterile spoon in the dish with the hypodermic syringe and needle, 
while others pr^er to use a tiny minim glaM. The tablet should be shaken 
out of the tube into the spoon or glass, which should be dry so that, if more 
than one tablet is shaken out, the unwanted ones can be replaced in the 
tube. Ten to fifteen minims of distilled water may be added to the tablet 
in the spoon or glass and when the tablet is dissolved the whole of the 
fluid should be drawn up into the syringe. 

Another method is to shake the tablet from the spoon into the barrel of 
the syringe, replace the piston, and then draw up into the syringe the 
10-15 tninims of distilled water as desired. A sterile swab may be held 
firmly over the lower end of the syringe whilst it is gently shaken up and 
dotvn in order to help mix the drug contained in the dissolving tablet 
with the water. 

Methods of charging a syringe from a phial and from a bottle are shown 
in figs. 151 and 152, p. 307. 

Having charg^ the syringe the air should be expelled by holding the 
syringe, needle pointing upwards, and slowly pressing the piston into the 
barrel, until all air bubbles have been expressed from the needle and a 
drop of the solution is seen at the end of it. 

In giving a hypodermic injection the nurse should first explain to the 
patient that he is going to have a slight prick, but, as the needle is sharp, 
it will not hurt very much. Then, choosing a portion of tissue fairly well 
covered with fat, such as lies over the supinator longus muscle on the 
extensor aspect of the forearm, cleanse the skin with ether or alcohol on a 
cotton wool swab, and then ci Aer grasp the tissue between the thumb and 
forefinger of the left hand or, if preferred, stretch the skin by pressure of 
the forefinger and tliumb, but in this case care should be taken to avoid 
bruising; the needle is then inserted beneath the skin parallel with the 
surface, grasp of the tissue is relaxed and the solution is gently, but not too 
slowly, pressed out of the barrel of the syringe by gentle pressure on the 
end of me piston, cither with the thumb or the palm of the hand. The 
needle is then withdrawn and as it leaves the skin a swab is placed over the 
puncture and held there for a few moments. If a tumour of fluid is visible, 
gentle massage in an upward direction away from the puncture should be 
used to disperse it. All hypodermic injections should be given in an up- 
ward direction as this corresponds with the flow of the lymphatic stream 
by means of whit^ the drug is about to be carried into the blood. It seems 
needless to say that in no circumstances should such an injection be made 
over a joint or over any part in which the fascia is taut. An injection made 
into such a locality gives unnecessary pain as the fluid, penetrating the 
dense tissue, causes local pressure. 

The intracutaneons route. For this method, which is employed with 
comparative rarity, an especially fine needle is necessary as the drug is 



3i8 administration of medicines and drugs 

injected into the substance of Ike skin and not beneath it. It is som^imes used in the 
administration of local anaesthesia, and also in the administration of toxin 
and antitoxin in the Schick and Dick tests, and also in the Schultz- 
Charlton and Mantoux tests. 

Intramuscular route. This is used when more rapid absorption is 
required than that obtained by the subcutaneous route, as for example 
in the administration of serum. It is also used when the substances in- 
jected, such as oily preparations, and preparations of quinine, might 
prove irritating if given more superficially. 

The apparatus required is similar to that for subcutaneous injection, but a 
larger syringe is used, since from 5 to 10 cubic centimetres are usually given. 
As in this method the needle is larger, and therefore makes a larger 
puncture, it is usual to provide a small collodion dressing to cover or seal 
this. The fluid to be injected should be warmed to the heat of the body by 
standing the phial in water for 10 minutes before administration, so that 
less pain may be caused and the fluid mord quickly absorbed. 

Method. Having charged the syringe and prejjared the skin, a large 
muscle is chosen, such as that of the buttock, the outer aspect of the thigh or 
the scapula region for the administration of large quantities, the dutoid 
and supinator longus being the sites commonly used for smaller quantities. 
The needle is plunged deep into the muscle at right angles to the skin — 
in the case of the buttock the needle is plunged right up to the hilt, the 
nurse steadying its passage through the skin by a forefinger placed on the 
hilt of the needle. The injection ^ould then be slowly but steadily made. 

Intraperitoneal route. Drugs arc rarely administered by this route, 
but it is one which is quite commonly used for the administration of saline 
to dehydrated babies; and more recently it is being used for the admin- 
istration of serum, which by this route is found to be almost as rapidly 
effective as by the intravenous method, with less possibility of the occur- 
rence of dangerous complications. 

Intravenous route . This is used when the most rapid action of the drug 
possible is necessary, as in diabetic or insulin coma, when insulin or 
glucose is necessary, but cannot be administered by any other route. To 
administer a small quantity of fluid by this route Uu following articles wUl 
be required — h 5 or 10 c.c. syringe and needle, ready sterilized, and if these 
have been placed in water they must be rinsed in saline or distilled water 
before an intravenous injection is made. For a larger quantity a Horrocks's 
flask should be provided (see fig. Gia, p. 175). It is becoming an increasing 
practice, however, to sterilize the articles us«d for this purpose either by 
boiling ^em in liquid paraflBn or by dry heat in an oven. An exceedingly 
sharp, finely grac^ needle is necessary, othenvise it may only pass over me 
surface of the vein as the physician attempts to insert it. 

Ether and swabs will be required, unth which to cleanse the skin, and a 
dry sterile swab to place over the puncture frur a few minutes when the 
needle is withdrawn. Seme physicians order a small collodion dressing 
to be applied. 

A light rubber tourniquet is af^lied to the arm in order to compress 
the veins so that the one chosen for injection stands well out, and whilst 
the tourniquet is being adjusted, if the patient is conscious and capable 
of movement, he shou^ be asked to dose his fist and flex and extend his 
forearm, or to open and dose his fist. 



MODES OF ADMINISTERINO DRUOS 319 

Method. A doctor always gives this injection. He will charge the syringe 
and expel all air, whilst the nurse steadies the patient’s arm and is ready 
to loosen the tourniquet when die doctor gives the word. He passes the 
needle into the distended vein, taking care to keep in the lumen of it, and 
not to pass through the vein — it is for this resison that the nurse keeps the 
parent’s arm very still — ^and when once in the vein he will require the 
tourniquet to be very gently loosened. He then withdraws the piston so 
that a little blood enters the syringe, which shows that he is in the vein, 
makes the injection slowly and evenly and, when this is completed, with> 
draws the ne^le. At the same time the nurse places the dry sterile swab over 
the puncture, flexes the arm onto this and holds it steady for a few moments. 
If the slight oozing of blood which may occur does not cease, she applies a 
collodion dressing. 

INHALATIONS 

The gases, vapours and fumbs of drugs arc inhaled either in order to 
produce a local effect on the upper respiratory passages through which 
the vapour passes, or to influence the circulation in the lungs and so 
either increase or decrease the bronchial secretions, or to allay spasm of 
the tubes by effecting alteration in the vasomotor 
control of the blood vessels, or bronchial vessels. 

Inhalations are also used as a means of producing 
the absorption of a drug through the lungs when 
a general effect is required as in the case of the 
induction of a general anaesthetic by this route, or 
when rapid absorption is known to occur and 
produce an effect on one of the other systems of the 
body, as in the administration of amyl nitrite in the 
treatment of angina. 

The drugs most commonly used to relieoe congestion 
in the upper respiratory passages are menthol and 
eucalyptus, administer^ either on gauze or in 
water. TTiose used as a respiratory disinfectant in puru- 
lent bronchitis and lung abscess include creosote, 
carbolic, iodine, oil of pine and friar’s balsam. 

Any of these disinfecting substances may be given 
by means of a Bumey-Teo inhaler, which consists of a 
frame of perforated zinc the edges of which arc 
bound, the inhaler being worn over the nose and 
mouth. A few drops of the drug — as ordered — ^are 
placed in the pad in the inhsder, which is then 
retained in position by elastic over the ears. Another method of 
administering this type of drug is by means of a ‘creosote bath’. One ounce 
of creosote is rapidly vaporized over a lamp placed in a closed room in 
which the patient sits or lies. His eyes are protected by gobies and his nose 
is li^tly plugged with cotton wool. He remains in this ‘ bath’ for a definite 
period, or pmods, each day, as ordered by the physician. 

Ammonia, vthich is inhaled in cases of fainting and syncope, irritates the 
mucous membrane and also reflexly stimulates the respiratory, cardiac 
and vasomotor centres, thus improving the circulation. It must ^ applied 
to the nostrfls with caution, and the eyes should be kept closed, as other- 
wise the conjunctiva will be very seriously irritated by it. 



Fio. 161. 

Bumey-Yoo’s inhaler 
— above, the interior 
is shown; below, the 
inhaler. 



320 ADMINISTRATION OF MEDICINES AND DRUGS 

Amyl nUrite is used in the treatment of some forms of angim pectoris. Uny 
capsules containing two or three minims of the drug are crushed in gauze 
and held to the nose for the patient to inhale, and, as the immediate effect 
produced is flushing of the face, head and nt^ as the drug causes dilation 
of the arterioles and capillaries, its effect on the spasmodically contracted 
coronarj’ blood vessels is thereby demonstrated. Amyl nitrite is also some- 
times used to relieve spasm of the bronchial tubes in cases of asdana. 

Stramonium. The dried leaves of this plant are burned and the smoke 
inhaled, or stramonium cigarettes may be smoked provided the patient 
can inhaile the smoke into his lungs. Stramonium relaxes the spasm of the 
bronchial tubes and is used in the relief of asthma. 

The leaves may be ignited in a small bowl and held under the patient’s 
nose. He should be instructed to close his eyes in order to avoid irritation 
by the smoke. If the leaves are not obtainable a little powdered stramon- 
ium may be ignited in the same way. Some sisters use a shallow dish, and 
make a stiff paper cone, placing the large wide open end in the dish and 
causing the patient to inhale the smoke out of the other, narrow end. 
Leaves of belladonna may be used in the same way and for the same 
purpose. 

Steam inhalations. Some of the drugs — such as menthol and 
eucalyptus — employed for the relief of nasal congestion, and the anti- 
septic drugs used in purulent bronchitis, may be combined with hot 
water and the vapour inhaled, but the volatility of the drug has to be 
considered when this method is used. Those which vaporize easily shotild 
be put into water not exceeding 120° F.; those which vaporize less readily 
may be placed in the receptacle first and have the water jjoured over 
them. It is impossible to inhale the steam from water hotter than 160° F, 
This is a point that all nurses should know and remember, as the patient 
may otherwise be caused considerable inconvenience and may even 
have his upper respiratory passages injured. 

Nelson's inhaler (see fig. 1 56, p. 309). This inhaler is supplied in various 
sizes, the average being that in which two pints of water will fill the in- 
haler to a point below the air inlet. This should never be covered, as if 
air cannot reach the fluid in the vessel the vapour cannot rise. The mouth- 
piece, which should always be boiled, is made of glass, and passes through 
a cork which fits the neck of the inhaler. It should be placed in the direc- 
tion shown in the illustration, fig. 156, letter A, or in the direction opposite 
to the air inlet, because, if it lay in the same plane as the inlet, when the 
patient breathed into Ae inhaler he would force steam out of the air 
inlet on to the region of his chest, and the moisture penetrating his cloth- 
ing might scald h^. 

The inhaler having been filled, it should be delivered to the bedside 
covered by a flannel bag which fits it, and standing in a wooden bowl or 
porringer as indicated (fig. 156, letter B). The patient sits up or leans over 
on one side, while the nurse arranges the apparatus and instructs the 
patient to place his lips to the mouthpiece — ^which may be protected by a 
piece of gauze — and to breathe in so that he receives the steam. He ooay 
breathe out into the inhaler, but this will cause steam to rise through the 
outlet, and it is better if he will remove his lips for a moment ffom the 
mouthpiece whilst breathii^ Out. In many instances the nurse will have 
to stand by the patient’s side steadying the inhaler for him. To inhale the 



INHALATIONS 321 

Steam which will rise from two pints of water will occupy from 15 to 20 
minutes. 

In some cases, particularly that of one with chronic bronchitis or winter 
cough, the patient is likely to be familiar with this treatment and so to be 
able to hold the inhaler for himself. It may be placed on a bedtable in 
front of the patient as he sits up in bed and, as it is adequately protected 
with a flannel cover and by die bowl or porringer in which it stands, the 
padent is not likely to be burnt. 

After a warm inhaladon the patient must not move about or go into 
places where the temperature varies but should remain in the same room. 



Fia. 162. — The Use of Nelson’s Fio. 163. — Method of Inhalino 

Inhaler. from aJug draped wrm a Towel. 

Jug inhalation. Any ordinary jug or a two-pint delf jam jar may be used 
for the purpose of an inhalation; but in this case, as there is no mouth- 
piece, the patient may wear a towel over his head in order to form a 
conopy under which to collect steam, or the mouth of the jug may be 
draped with a towel turban fashion to render the opening smsdl enough 
for the patient to apply his nose and mouth to it, as shown in fig. 163. 

A steam kettle is used when required to maintain a constantly moist 
atmosphere; when the steam tent method is employed a kettle of boiling 
water is arranged to admit steam into the tent, the latter contrived by use 
of a light covered-in framework attached to the bed. The tent should not 
be hotter than 75® F.; it is necessary for the tent to be well ventilated, and 
for this purpose air inlets and outlets should be provided. A steam tent 
is rather cumliersome and has been largely superseded by the modification 
of placing only a canofy over the head of the bed and providing a steam 
kettle as shown in fig. 155, p. 309. By thb method the difficulties of nursing 
a patient in a tent and of properly ventilating the tent are obviated. 

Administration of Oxygen. Deficiency of oxygen in the blood, which 
1$ described as anoxaemia^ is always serious, because the production of 
energy and heat by oxidation of food materials in the tissues depends upkon 
the presence of an adequate supply of oxygen in the blood. Deficiency of 
oxygen may arise in a number of conditions including cardiac fisilure 
— ^when the pulmonary circulation is poor — in disease of the lungs, as 
pneumonia, in chronic conditions of the lungs including emphysema, and 
in phosgene and chlorine gas poisoning. Anoxaemia also follows severe 
haemorrhage when the haemoglobin content of the blood becomes low. 



332 ADMINISTRATION OF MEDICINES AND DRUGS 

It occurs in cases of shock suid coUapse when the circulation of the blood 
is depressed, and as a result of carbon monoxide poisoning because the 
haemoglobin combines with this CO rather than with oxy^n. It also 
occurs when the absorption of oxygen is reduced owing to a very high 
altitude — at when flying or mountains climbing. 

When carbon dioxide is administered either it is combined with 
oxygen in a 5 or lo per cent, mixture, or dual cylinders — one of carbon 
dioxide and the other containing oxygen — are be coupled together on 
one stand, the tube leading from each cylinder being connected by a Y- 
shaped connexion piece to a single tubing which passes from the stem of 
the Y and conveys the mixture which is then regulated by the different 
valves on each of the cylinders and so administered to the patient. 

A variety of apparatus is employed for the administration of oxygen. 
It is ideal to have a fine adjustment valve attached to the oxygen cylinder 
and a combined flowmeter and humidifier. A WolflF’s bottle may alter- 
natively be used. 

Nasd catheter. Extra holes are cut in the end which is lubricated and 
passed 4 inches into one nostril and fixed to the patient’s face with strap- 
ping. By giving oxygen at 4 litres per minute a concentration of 30 per cent, 
can be delivered. 

Masai tubes. Tudor Edwards’s spectacle frame catheter carrier or Mar- 
riott’s catheter carrier may be employed. Both carry cycle valve tubing 



Fio. 164 . — ^Tudob EmvARDt’s 
Spectaclb Framb Catheter 
Carrier. 

which is lubricated with liquid paraffin and percainc, or cocaine ointment, 
and passed into the nostrils. This form of tubing is more comfortable 
than the nasal catheter. 

B.L.B. inhalation apparatus (Boothy, Lovelace, Bulbulian). This consists 
of three parts, the mask which fits the nose, hollow tubes pass from thb 
into one single tube, through a connecting regulator device to the reser- 
voir-breathing bag. The mask is adjusted by straps. The concentration 
of oxygen depends on having the airports on the connecting device open 
or closed. With all holes dosed the patient reedves over 90 per cent, 
oxygen when delivered at 6 to 7 litres per minute. He receives about 75 
per cent with two air-ptMts open when delivered at 5 litres per minute, and 
50 per cent when delivered at the rate of 3 litres per minute. This appar- 
atus will probably replace the use of the oxygen tent, except for cases witii 


Fw. 165. — ^Marriott's Head- 
piece AND Catheter Carroui. 


INHALATIONS 323 

facial injuries and those who will not tolerate wearing any apparatus — 
children, for example. 

There are two t^^s of mask, the nasal one shown below, and an oro- 
nasal mask, covering nose and mouth, for use when nasal breathing is 
obstructed. 

Oxygen Tent. When a patient, owing to facial injmries or because he 
will not tolerate it, cannot wear the BX.B. mask; if a high concentration 
of oxygen is necessary a tent is used. (See figs. 159 and 160, p. 312.) 

The Heidbrink tent is one of the latest, it is made of oiled cloth and is 
tucked under the mattress at the head and sides and under a blanket in 
front. The tent is first flooded with oxygen, then a flow of 4 to 5 litres per 
minute will maintain a service of 40 to 50 per cent, oxygen in the tent. 

Oxygen is passed into the tent by means of an injector. The pressure 
of the flow of oxygen causes the tent air to be syphoned out and drawn, 
with the oxygen, through the soda-lime tank and ice-chamber. The soda- 
lime removes carbon dioxide from the circulating tent air and the ice 
container serves several purposes; it causes condensation of the exhaled 



Fio. 166.— B.L.B. Oxygen Dsuvseino Mask m Sbotion (sbb auo Fio. 158, p. 31 1). 



324 ADMINISTRATION OF MEDICINES AND DRUGS 

moisture and maintains relative humidity, and it maintains the temixara- 
ture of the circulating tent air within a reasonable limit. A thermometer 
which for purposes of reading is outside the tent is attached to the chamber. 
The bulb of the thermometer lies in the tent-circulating-air-outlet stream, 
and so records the temperature of the tent air. The temperature should be 
maintained at 6o or 65 degrees Fahrenheit and may be regulated by 
running less of the oxygen through the ice-chamber. 

The tent air should be analysed in order to ensure that the percentage 
of oxygen decided upon by the physician is maintained. The absorber 
illustrated (see fig. 167) contains an ammonium chloride solution which 
absorbs oxygen. The bell tube with a fine capillary tube attached is 
inserted in the solution. The syringe is graduated (backwards) from i to 
100 and represents percentage. 



Fio. 167. — Oxygen Absorbing Appara- 
tus WITH Syringe Graduated Back- 
wards FROM 100 PER CENT. TO I PER 
CENT. 


To take a test of the tent air. Note the 
level of the abwrbing fluid in the 
capillary tube, then open one of the 
zip fasteners of the hood and plunge 
tlic syringe in and draw up the piston 
— the syringe is filled with tent air. 
Then gently squirt the air into the 
absorber when it will displace the 
absorbing solution in the bell tube, 
allow 20 to 30 seconds. Now gently 
withdraw the piston until the solution 
in the capillary tube rises to its pre- 
vious level. Lift the syringe and read — 
the reading 40 or 50 or whatever it may 
be is the percentage of oxygen in the 
tent, because the oxygen has been 
absorbed by the anunonium chloride. 

Precautions regarding fire. The inflam- 
mable nature of oxygen must never be 
forgotten and any articles likely to 
cause fire, or even any manipulations 
likely to result in sparks must be 
most studiously avoided. For example, 
smoking, the use of matches, lighters, 
night-lights, gas, electric light switches. 


wireless, an electric bell push (a hand bell can be provided) and in 
the case of children all sparking toys, toys provided with flints, toys 
which can be wound up and wM run quickly down so causing fidetion 
must not be used in the tent. It is important also to avoid causing sparks 


in combing the hair, or moving artificial silk or woollen clothing briskly. 
All such movements likely to cause sparking must be slowly and carefully 
carried out. Serious accidents have been caused by lack of suflUcient pre- 


caution in these respects. 


By means of the skin. Inunction is the mode most commonly em- 
ployed when drugs arc applied to the Ain in order that they may be 
absorbed and so produce their effect elsewhere in the body. 

The best examples are the use of belladonna in the form of a plaster 
and mercurial inunction by means of an ointmmt. 



INHALATIONS 325 

For mercurial inunction the skin should be prepared by washing with hot 
water and soap, and then drying it well, in order to soften the skin and 
bring blood well up to the surface. A soft part of the skin is chosen, such 
as the skin on the inner aspect of the arms or thighs, or of the axillae or 
groins, or the skin at the sides of the abdomen. When the axilla is chosen 
or whenever the part chosen is hadry, it should be shaved, because the 
fiiction emfdoyed while rubbing in the ointment will dr^ on the hairs ^ 
and cause pain and discomfort or even produce soreness. 

The amount of mercurial ointment and the strength in which it is to be 
used will always be specially mentioned on the order. The amoimt should 
then be carefully weighed, and warmed, and well rubbed in, a little at a 
time until the whole amount has been used. A note should be made of the 
area of skin treated. Mercurial inunction may be ordered daily or every 
other day, and different areas of skin should be used in turn as mercury 
is an irritant and may give rise to dermatitis. Mercury is a poisonous drug, 
and the nurse who is using it should therefore protect her hands either by 
wearing rubber gloves or by using a piece of lint with which to rub in the 
ointment when making the application. 

Ionization. By this means the drug is driven into the tissues locally by 
electricity, ions being used of some of the salts of the drug that has been 
specified. (This treatment is carried out by those specially qualified in 
medical electricity.) 


THE USE OF SERA AND VACCINES 

Serum is the liquid part of blood which has been separated from the 
solid part. When quantities of serum are needed blood is usually taken 
from an animal, although this is not invariable. 

An antitoxin serum is that obtained by collecting serum from an animal 
that has been inununized to some such disease as diphtheria or tetanus, 
by having been inoculated with the toxin. This serum is given in doses 
varying from 1,000 to 100,000 units or more. 

An antibacterid serum is obtained from an animal that has been immu- 
nized by innoculation •with the bacteria of the disease. Eixamples of this 
type arc antistreptococcal, antipneumococcal, and antimeningococcal sera 
which arc usually given in doses of to, 20 or 50 c.c. 

In both instances, the blood scrum taken from the animal contains the 
antitoxin, or antibacterial substance, which will neutralize the action of 
the toxin or organism and so rabe the resistance to that particular disease 
of the person to whom it b administered. If a sufficiently large dose is 
given, Ac effect may be to confer complete immunity, lasting for a certain 
time, and in Ab case Ac serum will be used as a prophylactic measure. 

When serum b adminbtered during Ac course of a disease as part of Ae 
treatment it b described as a curative measure. In thb case it acts by 
supplying Ae ready prepared neutralizing substances and so helps the 
patient’s body to combat Ac dbease from which he b suffering. Sera are 
usually given in Ae early stages of acute infections when Ae toxins are 
circulating in Ae tissues and Ae production of antibodies b relatively slow. 
At Ab time Ae administration of Ae ready prepared antibodies contained 
m Ae serum b an invaluable treatment. 

In the preparation of serum Ae horse b fi'equently used as, being a large 
animal, it b possible to tsdte a considerable quantity of blood from it 


326 ADMINISTRATION OF MEDICINES AND DRUGS 

without inconvenience. In the case of diphtheria and tetanus, the horse 
is injected with an exotoxin, and after a time is bled from the jugular 
vein, the serum is separated, some antiseptic added, and the serum is then 
concentrated so that a small dose of antitoxin scrum will contain a large 
amount of the antibody. The process of concentration at the same time 
removes a great deal of the protein material, and therefore the possibility 
of the serum reaction becomes less likely. On an average, antidiphtheria 
'serum contains 1,000-2,000 units in each cubic centimetre. 

Human convalescent serum is employed for the administration of the 
antitoxin in measles and anterior-poliomyelitis. 

Administration of serum. Serum may be administered in a variety 
of ways, including intravenously, intrathecally, by the intraperitoneal 
route, intramuscularly, and subcutaneously. It is important that scrum 
should be warmed to body heat before it is administered, and tliis can 
be done by standing the phial in a bowl of water at this temperature and 
not any hotter, for ten minutes until the serum is of the same heat as the 
water. If the serum is placed in very hot water the antibodies contained 
in it might be destroyed by the heat. Whatever mode of administration 
is chosen very strict asepsis is essential. 

Anaphylactic shock. After the administration of an initial dose of 
serum in some cases, but more often when the patient htis had serum 
before, and also in cases which are asthmatical, or have any tendency to 
allergic conditions, there is danger lest immediate and serious shock 
should follow rapidly on serum administration. 

The symptoms come on rapidly and may even begin to appear during 
the administration of the serum, in which case it should be stopped. 
Symptoms commonly met with are restlessness, pallor, dyspnoea; a rapid, 
feeble, irregular pulse, muscular twitchings, rigor and convulsions; and in 
serious cases the patient lapses into coma, and death may occur. Treat- 
ment is by the administration of adrenalin and atropine hypodermically. 

If danger of anaphylaxis is suspected the patient is desensitized to serum protein 
before administering the whole dose. This is carried out by the administration 
of a tiny dose — ^say, 0.0 1 c.c. — given intracutaneously; if the patient is 
sensitive this will be followed by a reaction which will be demonstrated by 
the appearance of an urticarial weal at the site of injection. This first test 
is usually followed in from half to one hour by giving i c.c. of serum sub- 
cutaneously, and if no local reaction arises it is then considered safe to give 
the whole dose within an hour or two. 

Serum Sickness. A milder degree of anaphylaxis, designated scrum 
sickness, may arise eight days after administration. These symptoms in- 
clude a serum rash, which is multiform in character and very irritable, 
joint pains, and a rise of temperature and malaise. Skin irritation may be 
relieved by calamine lotion. 

A vaccine is a preparation rather different from a serum. It consists of 
dead germs, or the toxins which have been obtained from them, suspended 
in saline solution; a vaccine therefore contains the same irritating sub- 
stances as does a germ, but in a much weaker form, rince in most instances 
the germs are dead before the vaccine is made. A vaccine acts as an antigen, 
a substance which stimulates the patumt’s tissues to produce antibomes. 



THE USE 07 SERA AND VACCINES 327 

Vaccines are used in the treatment of subacute and chronic conditions in order to 
raise the patient’s degree of resistance to the disease. They are also used 
to confer an active immunity, as for example in scarlet fever and diph> 
theria, and in some cases they are used as an aid to diagnosis and in other 
cases to test an individual’s susceptibility to a certain disease. 

Vaccines are usually administered hypodermically in doses of a con- 
venient size, i.e. in doses of l-i c.c. They may be put up in phials of this 
size or in small rubber-capped bottles, sealed with paraffin wax. The label 
states the strength in millions per c.c. 

After the administration of a vaccine, certain reactions occur. The nurse should 
anticipate and be able to recognize the severity of these. 

Loc^ reaction. This occurs at the site of inoculation and is demonstrated 
by the ordinary changes of inflanunation, with the usual signs of redness, 
swelling and heat. 

General reaction. As the result of the inoculation the general constitution 
is disturbed and the patient suffers from malaise, headache and a rise in 
temperature. 

Focal reaction. In any case where there is a focus of disease, as the result 
of the administration of a vaccine, the symptoms will be temporarily 
increased. For example, should the vaccine have been administered during 
the course of pulmonary tuberculosis, as is tuberculin, a focal reaction will 
be demonstrated by an increase in cough and sputum. 


CHEMOTHERAPY 

History. The use of chemicals which act directly on the bacteria in the 
blood dates from the use of quinine in the treatment of malaria. In 1907 
Ehrlich produced a synthetic preparation of arsenic specific in the treat- 
ment of syphilis, the world-famous ‘606’. Since then synthetic drugs have 
been produced which are useful in the treatment of tropical diseases most 
of which are due to tiny parasites called protozoa but it is comparatively 
recently, since 1 935, that synthetic drugs have been produced capable of 
acting on the germs of many of the ordinary diseases prevalent in this 
country. 

In 1935 Domagh demonstrated the use of prontosil in haemolytic strep- 
tococcal infections in animals. Prontosil is broken down in the body into 
a more simple compound known as sulphanilamide. The group of drugs 
described as sulphonamides dates from and includes sulphanilamide. 
Sulphanilamide was first tried out in the treatment of puerperal sep>sis by 
Drs. Colebrook and Kenny in 1936 who found that taking a fairly large 
series of cases over a period of almost two years the mortality in puerperal 
sepsis was, by the use of sulphanilamide, reduced from over 20 per cent, to 
below 5 per cent. Thus the value of stdphanilamide in the treatment of 
haemolytic streptococcal infection was proved and other infections due to 
the same class of organism such as other frmns of septicaemia, erysipelas, 
tonsillitis, osteomyelitis, and scarlet fever were successfully treated. But its 
value in dealing with offier infectioiut was less satisfactory and considerable 
research led to the production of other drugs all based on sulpfaonamide 
but being modified compounds of it. 

ExampUs of Svlphmaudde Drugs 

SulpkanUtmide (already mentioned} is used in the treatment of haemolytic 
streptococced irfections and b. coii infections of the uriitary tract. 



328 ADMINISTRATION OR MEDICINES AND DRUGS 

Sulphafiyridine M & B 693 was first tried out by Dr. Whitby at the 
Middlesex Hospital in the treatment of pneumonia. It is also valuable in a 
variety of infections including cerebrospinal fever and other forms of 
meningitis, gonorrhoea, and gas gangrene. 

Sulphathiazole or Thiazamide (M & B 760) is |>articularly valuable in 
staphylococcal infections and infections of the urinary tract. 

Sulphaguanidine is being tried out in the treatment of infecdons of the 
intestine, and has proved of pardcular value in the treatment of bacillary 
dysentery. 

Sulphadiazine. A preparation claimed to be less toxic than sulphathiazole 
which is used for the same purposes. 

Three other new compounds are Sulphasuxidine, an alternative to 
sulphaguanidine, stdphapyrazine and sulphamethaone. 

As each new compound is produced it is attempted either to produce a 
drug less toxic or more valuable in one or other sphere. 

In addition to those mentioned above there are dozens of trade prepar- 
ations of sulphonamide and sulphanilamide. 

Action oj the Drugs. All these compounds are bacteriostatic rather than 
bacteriocidal. They prevent the action of the organisms and inhibit their 
growth. Some drugs act better on one group of organisms than others and 
become the drugs of choice for use in certain disease. The best effect of the 
drugs is produced by maintaining an adequate concentration in the blood 
stream. 

Mode of Administration. The sulphonamide compounds arc usually 
given by mouth. They are rapidly absorbed in the sm^ intestine and in 
order to maintain an adequate concentration of the drug in the blood it is 
necessary to give it at regular intervals, day and night. If a patient vomits 
after taking liis dose the physician must be informed as he may wish the 
dose to be repeated. This b one of the instances when a patient should be 
wakened from sleep in order to be given his medicine. 

Dosage. The compound b prepared in tablets containing 0.5 gm. (half 
a gramme or 7J grains), they may be swallowed with a drink of water or 
crushed and mixed with water or milk. The dose usually recommended 
is 4 tablets statim and then 2 tablets four-hourly for 4 to 5 days: the dose is 
then reduced to i tablet four-hourly for the following 2 to 3 days. Larger 
doses are occasionally ordered. In the case of infants the dose b a quarter 
of a tablet for those under 3 months, half a tablet between 3 and 1 2 months, 
and one tablet for older infants. Children tolerate the drug well. 

Observations and precautions. Certain toxic effects may occur; 
nurses should watch for cyanosb, pallor, jaundice, skin'Tashes, headache 
and giddiness. In a few instances haemolytic anaemia or agranulocytosb 
(see p. 361) may arise; in order that the onset of this grave complication 
may be recognized immediately blood counts are made. Alteration of the 
haemoglobin pigments may result in methaemoglobin or sulphaemoglobin 
giving rise to dusky cyanosb, thb b not serious as it dem not interfere with 
the oxygen-carrying capacity of the blood. The condition may be treated 
by adminbtration of methylene blue, and it b generally considered ad^ds- 
able to omit food and me^cine containing sulphur, such as onions, <^;gs, 
magnesium sulphate and liquorice powder. 



CHEMOTHERAPY 


329 


During the administration of M & B 693 nausea and vomiting may 
be a troublesome accompaniment This may be avoided (1) by powdering 
the tablets and giving mem in milk or in sodium bicarbonate solution,* 
(a) by giving the drug in smaller doses and more frequently, instead of two 
tablets every four hours, one may be given every two hours. A soluble 
form ‘dagenan sodium’ is available for intramuscular injection when 
vomiting with the oral compound is persistent, and in cases in which it is 
essential to get a high concentration of the drug in the blood without 
delay. 

Plenty of fluid should be given, at least six pints a day is the amount 
recommended as barley water, water and weak tea. The bowels should be 
kept acting by the use of liquid parafiin and of enemata when necessary. 
The amount of urine passed should be noted, and it should be tested for 
albumin. 


PNEUMONIA treated by M&B 693 




60 


* ^ *v • • 




SO 

i::« 

1 t t 

; ; : ; : 




40 

iwR 

• Jik V » 

: : ; : : 

: i i i i 


; ; i i ; 

30 

! 



t 1 1 1 1 

i : f i ; 


20 .. 

— iiL 


JI.M. ip 

i a S 'm 

i i t 

I 

r-- 

i i>i*h 

*-i§i : 
fr if ^ 


Fro. 168.— CJhart or a Chiu> of Five. 

On adminioD M &: B 693, 9 graromes, followed by 0.5 gm. four-hourly for two days 
and a half. Then, at the tmperature was normal bm me general condition go<^, the 
dote was reduced to 0.5 gm. twice daily, and 36 hours later the drug was discontinued. 






330 ADMINISTRATION OF MSDICtNES AND DRUGS 

The accompanying chart illustrates the result obtained fi<om giving 
M & B 693 to a little girl of five years. She was admitted in the early days 
of pneumonia, seriously ill, very cyanosed, and suffering fiom marked 
dyspnoea with a typical expiratory gnmt and movement of the alae nasi. 
Her temperature declined within 36 hours after the initial dose and she 
made an uneventful recovery. 

Local Application of Sulphonamide pQwder is made in the case of wounds 
likely to be infected or 'M^ch are infected, in severe bums and in the treat- 
ment of certain skin infections such as impetigo; and recently it has been 
employed within the peritoneal cavity in cases of acute abdominal in- 
fection. When nursing all of these cases it is essential to be on the watch 
for the symptoms of toxaemia described above. 


PENICILLIN 

Penicillin is a new substance. It is not a sulphonamide. It was dis- 
covered by Professor A. Fleming in 1929 quite accidentally, who, whilst 
making experiments, noticed that a mould had grown on some of his 
culture plates and that when incubated the bacteria, in the parts covered 
by mould, did not grow. This mould is penicillin notaium, similar to the 
mould which forms on jam. In 1 940 Professor Florey and his fellow workers 
at Oxford produced an extract from the mould capable of being used for 
therapeutic purposes. 

Uses and characteristics. Penicillin acts on a great many pus-producing 
organisms including staphylococci and streptococci. It is bacteriostatic 
in that it prevents bacteria from growing but does not kill them. But it is 
harmless to the tissues and therefore the natural resistance of the tissues 
overcomes the invading organisms. There is no danger of giving an over- 
dose of penicillin because it is harmless to the body and docs not pi'oduce 
any toxic symptoms. The action of penicillin is not affected by the presence 
of pus. It is rapidly excreted by the kidneys and therefore administration 
must allow for this and be prescribed in such a way as to ensure the 
continuous presence of the drug in the blood stream. Penicillin is destroyed 
by the action of gastric juice so that it cannot be given by mouth. It is 
affected by exposure to the air and should be treat^ with care and only 
uncovered when in use. 

Dosage and modes of adminislratioH, PeidcUlin is given by the intravenous, 
intramuscular and subcutaneous routes. It is often ^ven by tlie drip 
method. It can also be injected into cavities, such as the pleural cavity and 
joint cavities and into abscess cavities. It is prepared in solution, paste 
and powder forms. 

Penicillin is prepared in different strengths. 

A biolc^cal unit, known as the Oxford unit has been standardized. From 
100 to over 5,000 units may be contained in a c.c. For general administration 
one hundred and twenty ^ousand units may be prescribed, by the drip 
method, to be given over a period of twenty-four hours; for intramuscular 
injection from five thousand units may be given at regular intervals. 
Lxal application is made by means of liquid, powder or paste and the 
application should be firmly maintained in position. 

Record of ^ogress in treatment is made by means of repeated bacterio- 
logical spedmens. 



PBNICILUN 331 

Nursing observalions. The general condition of the patient will be seen to 
be improving, he becomes l«s toxic, brighter and more cheerful. His 
appetite improves and he begins to sleep well. At first these symptoms are 
not always accompanied by a decline of fever and a patient may continue 
to run a high or swinging temperature for some days sifter general improve- 
ment has been noticed. When penicillin is locally applied the signs of in- 
flammation will disappear and pus will be replaced by a serous exudate. 

Hormone therapy is the term applied to indicate the therapeutic use of 
the group of drugs of endocrine origin. These are different from other drugs 
in that tiiey are normally present in the body. Their functions are studied 
by the effects produced when these substances are present in excess and 
they are employed to relieve the symptoms which result from deficiency 
of these substances and also in order to produce the known effects, as for 
example when adrenalin or epinephrine is employed to stimulate the sympa- 
thetic nervous control of involuntary muscle and when pituitary extract is 
given to stimulate the uterus, the intestinal muscle or the involuntary 
muscle in the walls of the blood vessels. 

The endocrine preparations most commonly used arc those of the 
following: 


Gland 

Pancreas 

Thyroid 

Parathyroid 

Adrenal 


Pituitary 

(posterior lobe) 

Pituitary 

(anterior lobe) 

Ovary 

Testis 

Liver and Stomach 


Extract and dose 
Insulin 10 to 15 units. 

Thyroideum i to 5 grains. 

Parathormone 20 to 40 units. 

Adrenaline i /600th to i /120th grain. Liquor 
adrenalinae hydrochloride 2 to 8 minims. 
Extract of adrenal cortex 5 to 40 units. 

Liquor pituitary 2 to 5 units. 

Oxytocin 2 to 10 units. 

Vasopressin 5 to 10 units. 

Extracts of the growth hormone, the gonado- 
tropic, thyrotropic, and adrenotropic are those 
principally used. 

Oestrone preparations such as oestradiol and 
stilboestrol (a synthetic preparation) and cor- 
pus luteum hormone progestin are employed. 
Androsteronc and testosterone are examples of 
testicular gland extracts. 

Extracts of the liver and stomach are known 
also to contain some hormonic preparation. 


Vitamin therapy (see p. 290 and appendix II). 



Chapter 20 

Poisons, and the Treatment of Poisoning 

Dangerous Drugs and Poisons Acts — Poisoning and its treatment — Examples of 
poisomng^ including gas poisoning 

DANGEROUS DRUGS AND POISONS ACTS 

T he Dangerous Drugs Acts were passed to control the sale and use 
of habit-forming drugs. The drugs which come under the Act arc 
morphine, cocaine, eegonine, diamorphine (heroin) and all pre- 
parations containing heroin — no matter how little. All preparations con- 
taining 0.2 per cent, or more of morphine and o-i per cent, or more of 
cocaine are also included. 

The parts of the Acts which specially concern nurses include the following: 
(i) Any amount of the drug, or medicine containing the 'drug, can only 
be used for the individual patient for whom it is ordered. These drugs can 
only be obtained on a doctor’s prescription; and, in hospital, when this 
prescription is written up on the patient’s bedcard. The prescription must 
contain the patient’s name and date, the exact amount of the drug to be 
given, the number of doses, and the signature or initials of the doctor. The 
prescription cannot be repeated, unless specifically ordered at the time of 
writing. 

(2) The stock of all such drugs should be kept in the poison cupboard 
in the ward and can only be supplied on the written requisition of the 
sister to the dispenser. The cupboard must be kept locked. The drugs con- 
tained in this cupboard can only be issued and used on the written instruc- 
tions on the medical card of a patient by the physician who is responsible. 
When the sister issues these drugs for use from this cupboard, they must be 
checked by a second person, and a note made of the amount issued. 

The Pharmacy and Poisons Act, 1933, was brought into being to 
restrict the sale and use of poisons. This is accomplished by including 
them in a number of schedules to which restrictions and exemptions apply. 
Schedules i and 4 are of interest to nurses, the fonner listing a very large 
number of drugs including arsenic, belladonna, digitalis, insulin, pituitary 
extract, nux vomica, &c. These must be kept under lock and key and the 
amount given checked before administration. 

To be able to purchase these drugs the purchaser must be known to the 
chemist, submit a signed statement of the purpose for which they are 
required and give name and address. Liniments and other poisonous 
substances for external use must be in poison bottles. Substances in 
schedule 4 can only be supplied upon a prescription, which is valid for one 
occasion only, unless directed by the doctor to be repeated. The drugs in 
this schedule include the barbiturates, veronal, &:c., atophan, amidopyrin, 
nitrocreasols and sulphonal. 

POISONING AND ITS TREATMENT 

Poisons may be taken by mouth, by hypodermic injection, or they may 
be absorbed through the skin or reach the blood stream by being inhaled. 

332 



POISONING AND ITS TREATMENT 333 

They may be taken accidentally or intentionally, and certain general 
principles are laid down for use in case of poisoning. 

Remove the poison from the stomach by giving an emetic or washing out 
the stomach; except when the poison taken is a strong corrosive, acid or 
alkali, in which case a demulcent is given. 

Give an antidote when possible, that is, if the character of the poison is 
known. 

Treat the patient for shock by application of heat, by raising the foot of the 
bed or couch on which he Iks and by giving him strong black coffee to 
drink or by rectal injection. Give rectal sidines. 

If the patient is drowy>, try to keep him awake and, particularly if his 
pupils are pinpoint, which may indicate opium or morphia poisoning, 'do 
not allow him to rdax for a moment. 

If the patient is in pain, and not writhing about excessively, apply heat 
to the abdomen and prepare the hypodermic of morphia which the doctor 
will probably order. 

If breathing is very shallow and slow, or has ceased, perform artificial res- 
piration, provided that the respiratory passages arc first clear of any 
obstruction, and, if oxygen and carbon dioxide are available, give inhala- 
tions of these. 

Antidotes include morphia for atropine and belladonna poisoning, 
atropine for morphia and opium poisoning. 

An acid, such as 4 ounces of vinegar, is used to neutralize poisoning by 
alkalis. 

An alkali, such as Epsom salts ^ ounce in 4 ounces of water, is used to 
neutralize acid poisons. 

Emetics include mustard, 1 tablespoonful, or salt 2 tablespoonfuls, in 8 
ounces of water ; tincture of ipecacuanha, 30-60 minims given in water; 
and apomorphinc hydrochloride, grains i /20th to i /6th administered by 
hypodermic injection. 

Demulcents. Milk, butter, olive oil, white of egg, gruel and barley water 
are the commonest demulcents employed when a corrosive acid or alkali 
has been swallowed. 

Stimulants. Brandy and whisky in water may be given by mouth; ether, 
30-60 minims, or strychnine hydrochloride, i/64th to i/32nd of a grain 
may be given hypodermically; aromatic spirit of ammonia, |-i drachm in 
water, or strong black coffee containing a little sugar may be given by 
mouth. Inhalation of smelling salts and the electrical current (faradism) 
applied locally are other means of stimulating a drowsy patient. 

SOME EXAMPLES OF POISONING 

When corrosive acids and alkalis have been takenj'the surfaces of the lips 
and mouth will be destroyed, and there will be considerable pain in the 
mouth, diroat and stomach, accompanied by collapse. In such instances 
the treatment indicated » to avoid emetics or lavage, to give one or more 
demulcents and to treat the patient for shock pending the arrival of a 
physician. 

Garbolte acid makes the lips and mouth white and hard, pain and 
collapse are very marked, and the urine is suppressed and green in colour 
(carboluria). When pure carbolic has been taken the treatment is as above, 



THE TREATMENT OF POISONING 


334 

but if the patient has swallowed a solution of 1/20 or i/io the stomach 
may be washed out with permanganate of potash solution, white of egg 
may be given as a demulcent, and magnesium sulphate in water as an 
alkali. Shock should be treated and stimulants administered freely. 

Oxalic acid (salts of lemon). This is not as destructive as pure carbolic 
so that stomach lavage can be administered with care. Lime and chalk 
should be given and the shock treated. 

Prussic acid (hydrocyanic acid). In this case the breath smells of 
bitter almonds, the respirations are sighing and gasping in character, the 
patient soon becomes unconscious with fixed stanng eyes and dilated 
pupUs. 

Treatment. An emetic may be given, as this acid is not powerfully corro- 
sive — ^that is, if the patient is not severely collapsed. Inhalations of 
ammonia should be given and stimulants administered freely and shock 
and collapse treated. 

Lysol. This is one of the exceptions in which the stomach is washed out 
when a corrosive has been taken. Brandy and water 1/4 is used for this 
purpose, and 4 ounces of magnesium sulphate solution are left in the 
stomach. Shock and restlessness should be treated. 

Arsenic (weed killer). Acute arsenical poisoning is accompanied by 
nausea, vomiting, diarrhoea and severe dehydration. The treatment con- 
sists in washing out the stomach and giving demulcents. 

Belladonna, and its active principle atropine, results in dryness of 
mouth and dilatation of pupils; the skin becomes hot and dry, the patient is 
flushed, the temperature is rawed, the pulse is rapid, and there is restless- 
ness and delirium. 

Treatment includes the giving of emetics — in addition pilocarpine nitrate, 
gr. J is given hypodermically — ^and the administration of sedatives to 
relieve the restlessness. 

Cocaine. Acute cocaine poisoning results in respiratory and cardiac 
failure with marked syncope. The treatment includes the administration of 
inhalations of ammonia and amyl nitrite, the giving of aromatic spirit of 
ammonia by mouth, and the use of strychnine hypodermically. 

Chloroform. The result of poisoning by chloroform is depression of the 
cardiac, respiratory and vasomotor centres followed by failure of respira- 
tion and failure of the heart’s action. The treatment is artificial respiration, 
the provision of fresh air, inhalations of ammonia and amyl nitrite, and 
the administration of poweiful cardiac restoratives, such as coramine 
and ether, hypodermically. 

Lead. In acute lead poisoning the mouth is dry and there is a metallic 
taste in the mouth, a blue line about the giuns, sensations of nausea, 
cramplike pain in the muscles and intestinal colic. 

The immediate treatment consists of rest in bed and af^UcatitMos of heat 
to the abdomen, with the administration of stimulants; and attempts will 
afterwards be made to eliminate the lead from the system by the adminis- 
tration of small doses of Epsmn salts. The patient should be removtxl 
from the possible source of lead contamination to which he is evidently 
susceptible. 



SOME EXAMPLES OF POISONING 335 

Mercury. Symptoms include soreness and swelling of the gums, 
loosening of the teeth, a metallic taste in the mouth, nausea, diarrhoea 
and vomiting, followed by collapse. The treatment is to wash out the 
stomach and give demulcents, particularly albumin water; shock is 
treated by stimulants and heat. 

Narcotics, including all hypnotics. As the patient will be drowsy 
and difficult to arouse, if he is not already in coma, the treatment aims at 
keeping him awake; emetics arc given, potassium permanganate being 
generally used for this purpose, and stomach lavage is employed for patients 
who are unconscious. Stimulants Such as coffee, administered either by 
mouth or rectally, and such stimulants as atropine, coramine and strych- 
nine are given hypodermically. Artificidl res^ration is performed when 
necessary. 

Phosphorus. Taking phosphorus results in pain in the throat and 
abdomen, with vomiting, and the vomit may be luminous in character. 
Treatment — an emetic of copper sulphate, i grain to the pint, is adminis- 
tered, followed by Epsom salts. Demulcents such as white of egg may be 
given, but oils should be avoided as these render phosphorus more soluble, 
and therefore result in further absorption of the poison. (Sec Phosphorus 
bums, p. 577.) 

Strychnine (vermin killer). Symptoms of strychnine poisoning are 
musciUar twitchings, cramp and convulsions. The treatment is to wash out 
the stomach, administer sedatives, give plenty of fluids and eliminate as 
far as possible all external stimuli, which woidd excite twitchings or con- 
vulsions — the patient is usually nursed in a darkened and quiet room. 


GAS POISONING 

Gas poisoning, whether deliberate or accidental, may be a very rapid 
cause of death. The places in which poisonous ^es are likely to be met 
are in the shafts of mines, the battened-down holds of ships, in garages 
where motor-car or aeroplane exhaust gases are not diffused freely and 
rapidly enough and in places where high explosives arc employed. Leaks 
from gas mains occurring in an ill-ventilated confined space may also give 
rise to gas poisoning. 

The symptoms of carbon monoxide poisoning begin zis dizziness, 
pass on to faintness and result in collapse which is followed by failure of 
respiration. If the subject remains exposed to the gas and untreated, death 
from deficiency of oxygen, anoxaemia, will occur. The lips and fingernails 
on a characteristic cherry-red colour, but this is not invariable. 

Carbon monoxide is not a poison. It is lack of oxygen which gives rise to the 
symptoms which are so severe and may terminate fatally. It so happens 
that the haemoglobin in the red blood cells has a much greater affinity for 
carbon monoxide than for oxygen, so that whenever the former gas is 
available the haemoglobin will combine with it, rather than with oxygen. 

Treatment. The patient should lie down, no exertion being permitted. 
Fresh air, and artificial respiration arc vaJuable; inhalation of carbon 
dioi^e 7 per cent, in oxygen should be given if available. A patient with 
anoacaemia is grey and cold, and as soon as he is breathing satisfactorily 
the shock from which he is suffering should be treated. 



Section 4 

Medical Conditions and Diseases and 
Their Treatment and Nursing 


Chapter 21 
Introductory 

The observation of symptoms — Insomnia^ the importance of rest and sleep in the 
treatment of disease — Varieties of pain, including types of colic — The manifestations 
of indigestion as a symptom of disease — Delirium 

T he practice of medicine is an ancient tradition, of Greek origin. 
Hippocrates is designated ‘the Father of Medicine’, and the oath 
which Hippocrates expected his students and followers to take 
before a degree was conferred upon them contains the sentiments of 
generosity and duty which have characterized the members of the medical 
profession throughout the ages. 

In this oath the young physician promises to use his knowledge for the 
benefit of his patients — ‘to give no deadly drug to any, though it be asked 
of me, nor will I counsel such, and especially I will not aid a woman to 
procure abortion’. He further promises that whatever house he enters, 
he will go there ‘for the benefit of the sick’. ‘Whatsoever things I see or hear 
concerning the life of men, in my attendance on the sick, or even apart 
therefrom, which ought not to be noised abroad, I will keep silence thereon, 
counting such things to be as sacred secrets. Pure and holy will I keep my 
Life and Art.’ 

A nurse may learn a good deal from studying the Hippocratic oath. 
Patients and their relatives often speak freely to a nurse, and what she 
learns about the patient and his family in this, or any other way, she must 
learn to look upon as sacred professional secrets. 

In the progress of the science and practice of medicine many other 
sciences have derived from it, as anatomy, physiology and psychology. 
Others have been adopted as essential to it including botany, chemistry, 
physics, pharmacology and bacteriology. As the study of mcdiQne extends 
a tendency has developed to separate this vast science into various fields, 
by specialization. In the wards of a general hospital, for example, will be 
found units devoted to the care of nervous diseases — in psychological 
medicine; skin diseases — ^in dermatology; the care of sick childrcrK-in 
pediatrics; as well as special units for the care of cases of infectious disease 
and pulmonary tuberculosis. 

In the following pages an introductory chapter deals with die observa- 
tions of some fairly common symptoms met with in disease. Then follows 
an outline of the care of diseases of the organs of the dnculation and 

33 ^ 




INTRODUCTORY 337 

S iration, of digestion, of the urinary tract, the nervous system, the 
>crine organs, infectious diseases and diseases of the skin. 

Symptoms may be described as evidence of disease. They are classified 
as subjective symptoms, which can be and often are complained of by the 
patient because they distress and worry him; other symptoms, which are 
not so evident to him but which are more often discovered by the doctor 
on examination, are described as objective. 

Symptoms are also classified as local or focal when they occur in a 
definite part, and general or constitutioned when they affect the various 
systems of the body. In inflammation, for example, the local symptoms 
present are heat, redness and swelling, and the general are those associated 
with any rise in temperature which may accompany the condition, or 
which may be due to a general disturbance of the body associated with the 
local discomfort. For example, a patient suffering pain will be unable to 
sleep, and this results in sensations of fatigue and weariness, headache 
and general aching pains, loss of appetite, and in time it will be the cause 
of loss of weight. 

A great de^ of the work of a nurse lies in her constant observation of 
symptoms, and her ability — which should be fostered and trained — to 
report on her observations with accuracy, not minimizing any one point, 
or ever exaggerating even in the slightest degree. Her work will probably 
be most valuable in coimexion with the subjective group of symptoms the 
discovery of which docs not require special examination. 

The observations made regarding tne condition of a patient on admis- 
sion (described on p. 23) will suggest a number of points which may help 
a nurse to give a doctor some assistance in his initial examination. The 
nurse will be more useful to him in this way if she has an idea of the 
various symptoms which may arise in association with disease of the 
different systems of the body, as outlined below. 

The digestive system. Subjective symptoms include thirst and dry- 
ness of the mouth, heartburn, loss of appetite and difficulty in swallowing 
food or drink, flatulence, indigestion, abdominal pain, vomiting, constipa- 
tion or diarrhoea. Objective symptoms include the condition of the mouth 
when examined, such as the state of the toi^e, whether dry or moist, 
pale or red, clean or dirty, furred or fissured; the lips, whether dry and 
cracked, and the presence or otherwise of any sordcs on them; the condi- 
tion of the abdomen, whether distended and whether any irregularities 
are present such as visible peristalsis or a very obviously enlarged liver or 
spleen. 

The circulatory system. The presence of dyspnoea, palpitation or 
pain, feelings of faintness, the character of the pulse (which is described 
m detail on p. 38) ; any pulsation of the veins of the neck, the presence of a 
malar flush or of cyanosis or pallor, coldness of the hands and feet, blue- 
ness of the tips of the fingers and toes and of the ears and nose; the presence 
erf any o^cma, and whether the skin pits on pressure. 

The respiratory system. (For types of dyspnoea, see details on 
p. 43, The character of the sputum is described on p. 64.) Pain in the chest 
fhmdd be considered and a^ the character of the pain, and whether it is 
fitill yfhing oT sharp and shooting; the presence of dilatation of the 



338 INTRODUCTORY 

alae nasi combined with the marked distress which accompanies laboured 
breathing should also be noted. 

Urinary system. The quantity and character of the urine should be 
investigate and compared with the normal as described on p. 58. Any 
dilBculty or frequency of micturition should be observed and the urine 
tested for abnormalities. 

Nervous system. The observation of fits, convulsions and coma arc 
described on p. 426. The condition of the eyes should be noted, particularly 
as regards the colour of the sclera, irregularity of pupils, the presence of 
squint and ptosis, and protrusion of the eyeball (exophthalmos). 

Any sensory symptoms present should be considered, such as pain, 
numbness, tingling, sensitiveness to touch (hyperaesthesia) and loss of 
sensation (analgesia). The condition of the skin, whether dry or harsh, 
shiny or moist, and any evidence of the presence of a rash. The presence 
of any paralysis, and whether this is of the spastic or flaccid type, and the 
pKwition in which the limbs lie when resting. Any difficulty the patient has 
in speaking or hearing should also be noted. 

A number of symptoms in which the accurate observations of the nurse 
arc invaluable have already been described in dealing with observation 
of the temperature, pulse and respiration, and excreta and discharges, 
including observations of urine, stool, vaginal discharges, vomit and 
sputum. Three other symptoms — ^insomnia, pain and indigestion^ — in 
which the observations of the nurse will be particularly valuable arc 
appended here, including notes on some of the measures which might 
be taken to procure their alleviation, and also the observations necessary 
when a definite form of treatment is ordered — such, for example, as 
absolute rest. 

INSOMNIA 

It is becoming increasingly common for patients to approach their 
doctors or attend at the consulting rooms of highly specialized neurolo- 
gists, complaining of insomnia. Possibly the treatment of this, which may 
be a difiSicult neurological problem, can hardly be considered to be within 
the province of the nurse, although she will often be exp>ected to help (see 
note on nemological nursing, p. 425). 

Nursing measures in insomnia. A nurse in a general hospital ward 
will often be faced by the problem of a patient who for some reason or 
another is imable to go to sleep. It is her duty to attempt to discover the 
cause, and she should investigate the different possibilities. For example, 
the patient may be hungry or thirsty, too cold or too hot, or his feet may 
be cold, his position uncomfortable — he may be lying on cr^es, on a 
moist sheet, or on crumbs. If he is wearing any suigical apparatus this 
may be uncomfortable, a bandage may be too tight, or a splint may be 
hurting at some particular point. He may be conscious of lack of move- 
ment of air around him, or he may wish to empty his bladder, or to use the 
bedpan. 

Smne of the symptoms of the complaint firom which he is suffering may 
be very irriuting and troublesome — ^he may be in pain or have a head- 
achy nis skin may be hot and dry, or he may be porsfwing heavily; or 
again he may have marked restlessness, or be sunering fttim dyqmoea, 



INSOMNIA 339 

palpitation, flatulence or indigestion, or be exceedingly uncomfortable 
because he has a very high temperature. 

Various little nursing attentions may be carried out in an attempt to 
relieve discomfort and to obtain the relaxation that is so necessary if the 
patient is to lie quiet and still, breathing regularly and with his eyes dosed 
— ^all of which are so important if he is to get to sleep. These measures in- 
clude giving the patient a warm, light nourishing drink, allowing him to 
empty his bladder, altering his position, rearranging his pillows, so that 
he is supported and his head is not nodding, straightening his sheets, 
tightening the undersheet, rearranging the drawsheet so that he lies on a 
cool part of it. Sponging his hands, and in some cases warm sponging the 
entire body, combing and brushing the hair, smoothly stroking ^e fore- 
head may ^ effective, or carrying the hands down over the side of the 
face and neck over the jugular veins may soothe. A cold compress or the 
application of an icecap may sometimes be effective in the relief of head- 
ache. 

It is equally important to sec that the patient is not facing or in any way 
irritated by a light; on the other hand, the patient may be distressed 
because he is in the dark and the provision of a suitably shaded nightlight 
may give the confidence which will render it possible for the patient so 
worried to relax. 

It is inadvisable to allow patients who are sleepless to read, and it is a 
great mistake to allow a patient to think that counting sheep going over a 
stile will help — this is an effort of concentration which wiU certairiiy keep 
him awake — but it is very important to get him to understand that 
muscular relaxation is necessary, and help him to practise this; and if, 
at the same time, he will think 'What a marvellous thing it is to go to 
sleep’, or ‘What a wonderful thing sleep is’, he will find his body becoming 
gradually more relaxed. 

A nurse should be very careful to avoid making a noise. She must move 
quietly, close doors gently, and make up fires without fuss or undue haste, 
'i’here must not be any whispering, or clattering of utensils, and she should 
see that beds do not creak. It is a great pity that so many of the hospitals 
in which our sick are nursed arc placed in the centre of some of our largest 
cities, often in the midst of traffic which is continuous until long past 
midnight and begins again at four or five in the morning. 

During sleep certain quite definite changes occur: the cerebral circula- 
tion is diminished and the blood pressure falls slightly; metabolism is 
maintained at a lower level than during waking hours, amd possibly 
the reason why people who are overtired are unable to sleep is that the 
fatigue products, produced in their muscles, result in the stimulation of 
certain metabolic activities which temporarily hinder the attainment of 
sleep. 

The causes of insomnia are too numerous to detail, but they may be 
divided into nervous fears and physical conditions, the latter being mani- 
fested by the painful symptoms which arc preventing relaxation. 

The use qf sedatives. In certain diseases the prognosis is rendered very 
grave unless reasonable sleep can be obtained, and to this end sedatives 
may be ordered, but the nurse should dearly undersUnd ffiat these are a 
last measure, and that they are drugs which by their action depress certain 
fao dt«<w and centres, and so may possibly give rise to an accumulation of 
toxins which would not occur during natural sleep. 



340 INTRODUCTORY 

When a patient is ordered a sedative the nurse must take pains to prepare him 
beforehand for sleep, so that, for example, he will not be likely to ask for a 
drink or a bedpan fifteen minutes after the sedative has been administered 
— all these matters should have been previously attended to. Any treat* 
ment the patient is having should have been performed; if the temperatme 
is being recorded four-hourly anti the sedative is ordered half an hour 
before this falls due, it should be given then, and a note made of the 
alteradon in time — not that the patient would be wakened should he have 
fallen asleep, but, by the application of common sense, to get as perfect a 
record of the temperature as possible. 

Report on sleep. With a patient for whom the nurse knows that sleep is of 
vital importance, she must make a very careful record of the amount 
obtained, and this should also be done whenever a sedative has been 
given. It is a good plan to include in the report : 

(a) The amount of sleep obtained altogether in hours and minutes. 

{b) The duration and die actual time of the longest sleep the patient 
had; e.g., he might have slept from i a.m. to 2.15 hours. 

(c) The character of the sleep should also be noted, whether it was quiet 
sleep, or restless and disturbed, or whether the patient slept only in short, 
fitful periods. 

REST A.ND SLEEP 

Rest might be considered to be the principle of practically aU treatment 
of abnorm^ conditions, both of body and mind. In many diseases, par* 
ticularly those associate with the febrile state and states of toxaemia, 
there is excessive wasting and destruction of the tissues of the body and 
deleterious effects are produced on the muscular system; this is productive 
of strain on the circulatory system and, by the state of rapid breakdown 
of tissue, extra work is thrown on the urinary system. All these and many 
other systems thus undergoing overwork and suffering from fatigue cry 
out for rest. 

Rest of the body is obtained by keeping the patient in bed; but he should 
lie quietly in b^, not restlessly fidgeting, jerking and turning. 

Rest of mind is of even greater importance, and to ensure this there must 
be absence of all worry, irritation, excitement and anxiety and all mental 
effort should be avoided. 

Further, in addition to the physiological rest, generally indicated above, 
mechanical rest of one or more of the organs may be obtained. For example, 
rest of the eye may be secured by covering it; or the instillation of some 
mydriatic, which paralyses the ciliary muscle, produces a similar effect. A 
limb may be rested by binding it securely on to a splint. 

Absolute rest indicates that the patient does not do anything for himself. 
He lies flat in bed with one pillow. He is washed and fed by the nurse. 
Two nurses are employed to move him whenever this is necessary. He is 
not allowed to read, t^, sew or perform any other kind of woric. 

The term ‘absolute rest’, however, is used with a variety of meanings. 
Some doctors say the patient is having absolute rest when he is at rest in 
bed, but performing the ordinary sanitary and toilet offices for himseff. 
The nurse must thenffore clearly understand what any individual physician 
means and requires when he orders a patient absolute rest, and until the 
gets this interrelation from him she riiould proceed as previoudy indi* 
cated. 



REST AND SLEEP 


34 * 

The application of rest in the treatment of disease will be mentioned in 
each instance. It is sufficient to state here that in certain conditions it is the 
only pKMsible available treatment as, for example, it is instanced in the 
frightened, rigidly still attitude of a patient simering from an attack of 
angina; and again, in the importance attached by every ward sister in the 
nursing of pneumonia to the degree of rest which the nurse is able to pro- 
vide for her patient, since this may be the sole means of preventing ulti- 
mate and fetal heart failure — ^when every pulse beat has to be economized 
and every irritating stimulus, however slight, eliminated in order to obtain 
the maximum degree of rest. 

Healthy sleep is practically the roost perfect condition of rest for mind 
and body and is looked upon as one of the most important factors in the 
treatment of disease. A patient should never be wakened from sleep — 
unless specially ordered, as in most cases sleep is more important than 
either food or treatment. Therefore, it is better to miss giving the patient a 
feeding, or recording a four-hourly temperature, for example, than to risk 
wakening him. On the other hand a patient who is apparently asleep may 
be in a condition of stupor, and it is very important that a nurse should 
be able to recognize the difference. 

There is anodier aspect that must be considered with regard to sleep — 
speaking for a moment of the normal person, it may truly be said that lack 
of sleep never killed anyone, and the layman’s idea that a person who does 
not sleep will eventually become mad is grossly inaccurate. But it must be 
recognized that a patient who during his normal life begins to sleep badly 
will most certainly be worried about it, and so worrying may contract the 
habit of sleeplessness — thus introducing one of the possible cause of 
insomnia. 


PAIN 

Pain is a very conunon symptom in disease and it often provides the 
physician with valuable information. It varies much in extent and degree, 
and is apt to be a very distressing symptom, producing not only physical 
but also mental distress. Although pain may accompany some normal 
physical processes, as instanced in the pains of laboiu*, it is usually an 
indication of an abnormal condition or disease. 

Another point to be taken into consideration is the reaction of the indi- 
vidual to pain, certain persons tolerating pain more readily than others. In 
some instances the degree of concentration may intensify the suffering; 
yet on the other hand, if the mind can be distracted, thepain is less severely- 
experienced. The memoty of pain is another very important factor, includ- 
ing the memory of any painful experience which may not necessarily 
have been physical, such as the induction of anaesthesia by the inhalation 
methods which the use of the barbiturate preparations has done so much 
to obviate. 

Varieties of pain. It is very important when dealing with patients to 
be able to follow carefully their description of the pain they have experi- 
enced and to apply it in a way that may help to determine the cause of the 
suf^ing. llie presence of pus in the tissues is usually indicated by a 
throWjii^ pain; disease of bone gives rise to a gnawing, aching pain; 
pressure tm nerves may result in tingling sensations, mimbness, hyperaes- 
oc analgesia; chronic inflammatory condidons of a nerve such as 



342 INTRODUCTORY 

occur in chronic neuritis and rheumatism give rise to a dull aching pain, 
paiticularly when the part is at rest and when it gets warm; acute nerve 
lesions such as neuralgia are characterized by shooting pains. 

Pressure caused by a too tightly applied splint or by plaster of pans is 
usually indicated by a hot burning pain, and the pain of a seroiu mem- 
brane is always sharp and shooting in character as is the pain of pleurisy. 

Most adults can give some lucid description of pain, but in dealing with 
infants and tiny children it may be necessary for the nurse to differentiate 
between a cry of pain and one that is due to temper or hunger. Generally 
speaking any restlessness, particularly at night, indicates pain in a child — 
a tiny child may be seen to put his hands frequently to his face, which 
might indicate earache, or the pain of cutting teeth; or the child might roll 
its bead about on the pillow or bang its head, although head banging is 
usually due to some nervous condition. 

Observation on pain in special regions. A nurse may be called upon to help 
determine the cause of pain in some special region, particularly in heacl- 
ache and in colic. 

Headache is a very common complaint and the causes appear to be 
endless. It is important to decide the situation of the pain — whether it be 
frontal, or occipital, or whether half the head or the whole is involved. 
Again, the character of a headache varies very much — it may be an acute 
unbearable pain which will only respond to the administration of drugs, 
such as morphia, or a constant dull aching pain, or a pain as if pressure 
i? being brought to bear upon the head, a penetrating pain of a boring 
character, or throbbing in diaracter, or a very intense pain only occurring 
at intervals. In most of these the patient is not utterly disabled, but is able 
to carry on with his ordinary routine duties, though he may be definitely 
suffering very grave, and perhaps unnecessary discomfort, and therefore 
the cause should always be investigated. 

Catises. In investigatmg the cause of headache the physician will usually 
go through the different systems and tiy and find out first whether the 
headache is associated wiA disorders of digestion or with constipation. 
Defective sight is another fairly common cause, and in this case the pain 
may occur over the eyes or at the occiput when the visual area is fatigued, 
so that a frontal headache at the end of the day and an occipital headache 
on waking in the morning might be considered an indication of eyestrain. 
Abnormsuities of blood pressure cause headache — in low blcod pressure 
it is due to anaemia of the brsun, and in high blood pressure probably 
due to pressure and congestion. Mental strain or any worry and anxiety 
frequently cause headache, and this includes the case of a child over- 
working at school or being unduly anxious about his lessons, or that of an 
older student who is being pressed to reach a standard of wdiich he is not 
really capable. Many diseases of the central nervous system have headache 
as a symptom, and any injury which gives rise to concussion of the brain or 
spinal cord will give rise to headache. 

Another very constant cause of headache, particularly in diseased con- 
ditions, is toxaemia, and this is met with in nephritis particularly and in 
jaundice and toxaonia due to sepsis or constipation. A persistent headache 
may be traced to the presence of septic teeth or tonsils, a septic af^xndix 
or gallbladder, or infected cranial sinuses. Headache is a fii^uent symp- 
tom the moset of many febrik diseases, particularly an acute attack of 



PAIN 343 

influenza, pneumonia and typhoid fever, scarlet fever or smzdlpox, and 
the headaches associated with erysipelas and tetanus are severe beyond 
description. 

Another very potent cause of headache in women is interference with or 
disturbance of the functions of the reproductive organs; ovaritis and 
uterine displacements (for example) are associated with headache. Many 
women suffer severe headaches at the onset of menstruation and again at 
the menopause. 

Treatment. As far as the nursing is concerned the aim will be to relieve 
the headache — it is the physician’s business to discover the cause, although 
the muse will be able to help by her observations and also by the fact that 
a woman patient will very often confide in her concerning matters which 
she might not so willingly discuss with the physician. 

An application of cold to the head will give some relief in most head* 
aches, and this may take the form of an icebag, cold compress, Leiter’s 
coils, or evaporating lotion. A hot bath, by stimulating the circulation 
and bringing blood to the lower extremities and skin, may also give relief; 
the application of heat or of some form of counterirritant, such as a mus- 
tard leaf at the back of the neck, may relieve the pain by a reflex effect. In 
headaches dissociated with low blood pressure or fatigue, a stimulant such 
as tea or coffee, a little caffeine or sal volatile may give relief; those due to 
a high blood pressure or to cerebral congestion may be relieved by the 
administration of a small dose of concentrated magnesium sulphate 
solution which produces some degree of dehydration. 

Drugs should be very carefully used and should never be advised by a 
nurse, because a person afflicted by persistent and continuous headache^ 
may become addicted to the use of drugs. Different preparations of aspirin, 
phenacetin and antipyrin are sometimes ordered by physicians, particu- 
larly when a headache is producing marked insomnia, which is quite 
definitely lowering the vitality of the patient. 

The usual considerations to be taken regarding further measures for the 
relief of headache include care in advising the patient regarding his diet 
and mode of life, particularly with regard to avoiding repeated fatigue 
and to obtaining sufficient sleep and rest; the condition of the bowels 
should be considered, as even if the patient has a daily bowel action he may 
still be constipated, as the stool may be insufficient in amount, and the 
amount of urine passed should be very carefully considered and the urine 
itself tested. 

Colic. Colic is an intermittent, usually acute pain, produced by the con- 
traction of the involimtary musdes contained m the walls of some of the 
hollow viscera and tubelike structures passing fi'om one organ to another, 
particularly in the case of the ureters in renal colic and the bile ducts in 
biliary colic. 

Gastro-inteslinal colic. This is the commonest type of colic, and is due to a 
variety of causes. It may be the result taking indigestible food, or of food 
poisoning. The ingestion of lead gives rise to lead colic or painter’s colic, 
file ccdic met with in prussic add poiseming is very acute. In some persons 
colic appears to be of nervous oj%in,^ as anxiety and worry pve rise to an 
attack. During an attack of gastro-intestinal^ colic the patient is seized 
with pain in the abdomen, and may describe his intestines as 'all tied up in 
^ots’; he grasps his abdomen with both hands, curls himself into a ball 



344 INTRODUCTORY 

and draws his knees up on to his abdomen. In a few moments the attack 
subsides and he fzills back more or less exhausted. This type of colic may be 
accompanied by diarrhoea or vomiting, or constipation may be present, 
particularly in the form due to lead coUc. The severity of the pain results 
in a considerable degree of shock, which is probably contributed to by 
fear of the impending and almost certain attacks of pain; the patient is 
extremely restless, his face is pinched, his expression anxious and his pupils 
often dilated with pain, his tempierature is usually subnormal, his pulse 
weak, his respirations shallow and rapid and his skin cold and clammy. 

Treatment. The treatment is aimed at the cause; but apart from this 
when a nurse is in charge of a patient with intestinsd colic she must try to 
relieve it, and applications of heat to the abdomen during tlie attack may 
cause it to abate. As a general rule an aperient should not be administered, 
but in the case of children, who may be susp>ected of eating indigestible 
food, a dose of castor oil may be administered. If a doctor is available he 
may order the addition of a little laudanum to this. For severe intestinal 
colic morphia will probably be ordered. The nurse should always see that 
the patient is kept very warm, his cold wet skin should be wiped dry 
between the attacks and, if the patient can take fluid, small drinks should 
be given. 

Renal colic is due to the passage of some abnormality down one or both 
ureters — this may be crysuls, stones or a bloodclot. The pain begins in the 
loin and passes down the affected ade to the groin and then to the inner 
side of the thigh; it is markedly severe, and strong men have been known 
to twist the brass rail of a bedstead in the agony they suffer during an 
attack of renal colic. This pain is accompani^ by great restlessness and 
anxiety, and frequently also by vomiting, and is followed by a considerable 
degree of shock. It is aJso accompanied by a constant desire to pass urine, 
though micturition may be painful. There is usually some degree of 
haematuria. 

Treatment. Morphia is usually ordered for the relief of pain in renal colic. 
During the attack the nurse should do her best to alleviate the pain by hot 
applications over the loins or by the use of counterirritants and by en- 
couraging the patient to take hot baths. The cause must be investigated, 
and medical treatment aims at keeping the urine diluted. It is therefore 
good nursing treatment to administer large quantities of fluid during an 
attack of renal colic. 

Biliary colic. The pain in biliary colic is similar to that in renal colic and 
is due to a similar cause. In this case probably a gallstone or some 
thickened bile is blocking a bile-duct and the increased peristalsis giving 
rise to pain is nature’s effort to expel the foreign body along the duct. The 
patient will describe this pain as knifelike in character, passing from the 
right side over the epigastrium and up to the ri^ht shoulder. It is severe, 
the patient is restless and rolls about in bed writhing with pmn, and al- 
though vomiting accompanies the attack it brings no relief. The attack is 
followed by colkpse. Jaundice may follow an attack of biliary colic if a 
stone bloc^ the common duct, though not otherwise, so that jaundice 
is not considered a symptom of biliary colic, but a symptom of Uockage 
of the duct. (Sec also cholecystitis, p. 394.) 



INDIGESTION 


345 


INDIGESTION 

Indigestion or dyspepsia is a very common symptom which may be due 
to an enormous variety of causes, including the partaking of badly cooked 
meals and unsuitable foods; eating too rapidly, too frequently or too infre- 
quently; the injudicious use of tea, coffee, alcohol or tobacco; neglected 
dental h)^ene, constipation, disorders and diseases of the stomach, and a 
number of other causes which include worry and bad temper and other 
emotional excesses. 

When a nurse is asked to make observations on the condition of a patient 
who complains of indigestion, she must first bear in mind the large number 
of contributory causes which may be involved; she should next note which 
foods disagree with her patient and which he can take without discomfort; 
whether the indigestion complained of occurs after every meal or only at 
certain times of the day. In the case of peptic ulcer (for example) the pain 
will be experienced at a varying time ^ter meals; in disorders of the gall- 
bladder the discomfort may accumulate towards the end of the afternoon 
and the beginning of the night. A nurse should also notice whether it is a 
full or an empty stomach which produces discomfort. In some cases of 
duodenal ulcer the pain is relieved by taking a small quantity of food; 
in others, as in gastric ulcer, pain can only be relieved on emptying the 
stomach by vomiting. 

It is essential for nurses to remember that indigestion is not only 
associated with disorders or diseases of the stomach. There is a vast field of 
reflex causes of indigestion, and it is not an exaggeration to state that 
indigestion may be Ae only troublesome symptom complained of in the 
early stages of many serious conditions such as cardiovascular disease. It 
may for example be the first symptom of a slight degree of hypertension 
of the heart associated with arteriosclerosis and high blood pressure; or 
again, it may be a very distressing symptom in coronary thrombosis; 
whilst the part which indigestion plays in any functional derangement of 
the heart is more common than either palpitation or tachycardia. 

R^x indigestion may also occur whenever any part of the alimentary 
tract is displaced, disordered or diseased. It is well known that constipa- 
tion and visceroptosis give rise to indigestion, but it is less well known that 
even slight displacement of the lower part of the large intestine which 
may for example arise as a result of enlargement of the uterus by a fibroid 
tumour, or simply as the result of retroversion of that organ, very slightly 
altering the position of the pelvic colon, may be the cause of the symptom. 
Appendicitis and cholecystitis may be disguised for months under the 
cloak of indigestion, and — to mention one or two other organs — disease of 
the hin gn and kidneys noay be manifested for a considerable time by 
indig»uon. Many nurses are familiar with indigestion as one of the 
recognized modes of onset of pulmonary tuberculosis which, accompanied 
by nausea and vomiting, render the victims so difficult to care for, as the 
food needed in the treatment of this wasting disease becomes so difficult to 
administer. Few perhaps realize the discorrfort that indigestion produces 
in many cases of pneumonia— the patient, desperately inconvenienc^ by 
his many distressing symptoms, does not differentiate between pain in his 
chest and pain due to indigestion, and it is for this rca.son that in such 
cases small doses of easily digested fluids should be given, distension of the 



346 INTRODUCTORY 

Stomach being carefully avoided because of its dose proximity to the heart, 
which is bearing the strain of the grave toxaemia from which the patient 
is sufferii^. 

Before tke treatment of indigestion can reasonably be undertaken investigation of 
the cause and diagnosis of the condition should be rnade. The nurse’s part will be 
to contribute an accurate report bf any observations she may have made, 
or any history she may have been able to elidt. 

A ^scased stomach will be treated by rest but, apart from the treatment 
of severe haematemesis, when two to t^e days’ complete starvation may 
be considered as a preliminary, rest to the stomach does not mean keeping 
it empty. The prindplcs of treatment undertaken in these cases include : 

(1) A choice of food which is bland and non-irritating, such as diluted 
or dtrated milk or white of egg. 

(2) The administration of small quantities, 1^3 ounces at first, increas- 
ing to not more than 5-6 ounces at interv^ of 1^2 hoius. A diseased 
stomach functions most easily when it contains a small quantity of non- 
irritating food. 

(3) Fluid is essential for the wellbeing of the body and, in cases of 
disoidcrcd digestion, it ought to be given half to three-quarters of an hour 
before food, rather than vwth it. 

(4) As one part of the alimentary tract is so dependent upon other parts, 
the teeth should be carefully examined and the hygiene of the mouth 
maintained in as perfect a state as possible; the hygiene of the colon 
should be similarly considered and constipation carefully avoided. 


DELIRIUM 

Delirium is a confusion of the mind which may vary from slight dis- 
turbance to severe mania. It occurs easily in children as the result of a 
slight rise in temperature or gastro-intestinal disorder. In adults it accom- 
panies more grave states of fever and toxaemia. The mind is confused 
and the patient does not recognise his surroundings, he may lie quietly 
chattering to himself or become noisy and violent. Acute delirium when the 
patient shouts amd struggles is very exhausting and he quickly becomes 
prostrated. In coma-vigil he lies with widc-op>cn eyes, staring at the ceiling 
and quietly muttering. This form accompanies grave toxaemia, as in 
typhoid fever. In delirium tremens the patient is terrified, he imagines he 
sees unpleasant moving objects such as snakes and vermin; he is restless 
and covered with perspiration. Unless the condition can be relieved he 
will become gravely exhausted (for treatment of D.T’s, see p. 647). 

In the nursing of delirious patients, a patient who is attempting to get 
out of bed shoiud be given a bedpan or urinal in case the desire to pass 
urine or stool is making him restless. He should also be given a drink or 
offered some form of nourishment as he may be hungry. A delirious patient 
should generally be humoured rather than restrained. The nurse must 
discover the best treatment for each; some resent being touched, others 
will relax if gently handled. Some can be reassured, others will be more 
excited if spoken to. A nurse must never show that she is afraid; she must 
act kindly but firmly and without any hesitation. 



Chapter 22 

Diseases and Disorders of Heart and Organs 
of Circulation 

Pericarditis^ endocarditis^ myocarditis — Congenital heart disease^ functional heart 
disease — The symptoms^ treatment and nursing of cases of heart disease — Cardiac 
syncope — Angina pectoris — Coronaty thrombosis and embolism — Cardiac asthma — 
Diseases of the blood vessels — aneurysm^ arteriosclerosis , arteritis and atheroma-^ 
High blood pressure — Low blood pressure — Diseases of the blood — anaemia^ 
diseases of the white cells — splenic anaemia^ leucocytosis and leukaemia^ haemophilia, 
purpura, poly<ythaemia — Diseases of the lymphatic system — adenitis, lymphangitis, 

and lymphadenoma 

VARIETIES OF HEART DISEASE 

H eart disease may be congenital or acquired. Practically any form of 
microbic disease can effect the heart, acute rheumatism, influenza, 
diphtheria, pneumonia, acute nephritis, and streptococcal infec- 
tions of the ear, nose and throat, such as tonsillitis, may all be causes of 
heart disease. 

Acquired heart disease may affect the pericardium, myocardium or 
endocardium, producing pericarditis, myocarditis and endocarditis respec- 
tively, and one, two or all three of the layers of the heart may be involved 
in the infection. Organic heart disease may be acute or chronic. Functional 
disorder of the heart may exist apart from organic changes. 


PERICARDITIS 

Pericarditis is conunonly associated with acute rheumatism. It is very 
disabling and is the source of much of the cardiac disease met with in 
children and young people. 

The changes which take place in the pericardium vary according to 
tlie stage of the disease. In the early stage a layer of fibrin is formed 
between the pericardial layers, rendering the surfaces slightly roughened 
and causing pain on movements, A little later on in the disease the serous 
membrane secretes fluid in excess and this, poured out between the layers, 
separates them and causes the pain to be less, but the pressure of the fluid 
in the pericardial sac further embarrasses the action of the heart. Much 
later in the disease, the fluid is absorbed and the roughened layers of 
membrane adhere together, adhesions form between them and the con- 
dition known as an coherent pericardium arises. In addition adhesions form 
on the outer surface of the pericardium and cause it to become fixed to 
the adjacent structures, suen as the diaphragm. 

Symptoms. In addition to the symptoms mentioned later (on p. 350), 
which arc found in all forms of heart disease as the result of cardiac failure, 
certain symptoms arise which are characteristic of pericarditis. Pam, due to rubbing 

347 



348 HEART AND ORGANS OF OIRCULATION 

together of the inflamed serous membrane, is felt over the sternum in the 
precordial area. 

The rate of the pulse is increased owing to embarrassment of the action of 
the heart. 

Dyspnoea occurs, breathing is thoracic in character and very rapid, and 
abdominal movement is al^nt. The patient has to be propped up on 
pillows in order to lessen the discomfort. 

In a severe case of pericarditis the patient is very ill indeed and may die 
from cardiac failure. If he recovers, some of the fluid may be removed (see 
aspiration of the pericardial sac on p. 204). If adhesions form the apex 
beat is seen to produce a wide ripple of movement instead of die usual 
small impulse, and in children the intercostal muscles may be indrawn by 
the tug exerted with each contraction of the heart which is bound down 
by adhesions to the wall of the chest. 

Treatment. In addition to the treatment described on p. 351, when 
pericarditis is rheumatic in origin salicylates are administered. Counter- 
irritants are applied over the precordium both to reduce the inflammation 
and to relieve the pain. Some form of hot application such as antiphlogis- 
tine may be employed, or a mustard leaf may be used, or blistering. 

The nursing care of pericarditis includes observation of the chart for 
variations in temperature and careful watching of the pulse and respira- 
tion in addition to the administration of absolute rest indicated in all 
cases of serious heart disease. 

ENDOCARDITIS 

Endocarditis, or disease of the endocardium, affects the valves of the 
heart and produces valvulitis or valvular disease. As the result of inflamma- 
tion of the valves deposits of lymphoid tissue form on them; later on, tiny 
growths described as warty vegetations are formed; and, still later, fibrous 
tissue is deposited and, when this contracts, it results in scarring which 
may produce narrowing of the valvular orifice. 

As the result of the changes described above tlie affected valve or valves 
— as a rule the aortic and mitral valves are affected in endocarditis or 
valvular disease-— undergo one of two changes: 

(a) Incompetent closure of the valve results in regurgitation of blood, or leakage 
into the chamber behind the valve because, owing to the presence of 
adhesions, it is unable to close properly. 

{b) Obstruction or narrowing of the valvular orifice may be present, and in 
this condition, described as stenosis, part of the lumen of the valve is per- 
manently closed by the contracted fibrous tissue — ^which results in 
scarring — and the passage of blood through the opening is partially 
obstructed. 

Symptoms of valvular disease. The symptoms present vary accord- 
ing as the mitral or the aortic valve is affected. In mitral disease the pul- 
monary circulation is first affected and the symptoms are — palpitation and 
dyspnoea on exertion, with a characteristic malar fiush and, in severe cases, 
marked lyanosis. Pain over the heart is complained of, and this is associated 
with palpitation. As heart failure occurs the feet and ankles swell towards 
the end of the day. 

In aortic disease the systemic circulation is primarily impaired and the 
patient is pale, complains of dizziness and faintness on the least exertion and 



ENDOCARDITIS 349 

has pain behind the sternum due to the insufficient supply of nourishment to 
the cardiac muscle. The pain is anginal in character (sec also angina, 
on p. 354). 

Malignant endocarditla is a very severe form of an acutely infective 
character which results in ulceration of the valves; small particles of the 
friable ulcerated tissue break away and, travelling in the circulation, 
give rise to the formation of embolic abscesses in various parts of the body. 
The patient is seriously ill; the temperature is high, and rigors occur; 
there is marked wasting and grave prostration. The condition of the 
patient may resemble that of septicaemia. In many cases malignant 
endocarditis terminates fatally, and in cases where recovery takes place 
it is slow, weakness and prostration are marked and convalescence is very 
protracted. 

MYOCARDITIS 

Myocarditis is inflammation of the myocardium; it may be due to any 
microbic infection and is found associated with acute rheumatism, in- 
fluenza, typhoid fever and diphtheria. The condition may be acute or 
subacute and an acute myocarditis may become chronic. 

Symptoms. The function of the heart is seriously affected in myocar- 
ditis, the sounds are feeble, the rate increased, the rhythm irregular and 
the heart is dilated and flabby. Palpitation and dyspnoea occur on slight 
exertion, and the danger of fatal heart failure is Sway's present. 

CONGENITAL HEART DISEASE 

Congenital heart disease is due to defective development of the heart. 
It may be present in a serious or in a minor degree. Serious disease may 
be due to the absence of a septum — a bilocular heart. There may be absence 
of either a ventricular or auricular septum, giving a heart with three 
chambers — a trilocular heart. Both these conditions are incompatible with 
any length of life. 

Less serious disease is seen when there is incomplete development of a 
septum and the blood on both sides is mixed. Another form is described 
as a patent ductus arteriosus, meaning that the opening which exists in the 
foetal heart, between the pulmonary artery and the aorta, does not close 
at birth, as it should do, and that consequently arterial and venous blood 
mix and the baby is cyanosed and is called a blue baby. Dextrocardia is the 
transposition of the heart to the right side of the chest. 

The symptoms of congenital heart disease are cyanosis and 
dyspnoea, which may be serious and alarming and h constant or paroxys- 
m^, according to the severity of the condition. If the baby survives he 
will be subject to bronchitis and broncho-pneumonia and to infective 
conditions. If he grows up, clubbing of the fingers may be seen, and the 
conditions of cyanosis and dyspnoea usually persist. 


FUNCTIONAL HEART DISEASE 

Functional heart disease is also described as D.A.H., or disorderly action 
of the heart, because the action is deranged although there is no organic 
disease present. 



350 HEART AND ORGANS OF CIRCULATION 

The cause may be of nervous origin resulting fiom a disturbed emo- 
tional state, or it may be due to the excessive use of alcohol, tobacco or 
drugs. 

The symptoms of hmctional heart disease are very numerous and 
may be much more distressing to the patient dian the symptoms of serious 
organic disease. Symptoms such as indigestion, constipation, palpitation, 
breathlessness, insomnia, sweating, fainting and tremor are l^quent. 

The treatment includes the investigation for the presence of toxaemia, 
vdiich might be a a>ntributory factor, and the general standard of health 
should be improved. 


SYMPTOMS OF FAILING CIRCULATION 

Symptoms of failing circulation arise from the failure of the heart to 
pump blood into the organs, or to pump it with sufficient force to return 
the blood in the venous system back to the heart. This disability of func- 
tion is described as ‘back pressure’ because, instead of the return of the 
blood to the heart for proper maintenance of the circulation, stagnation 
tends to occur in the various organs, resulting in impairment of their 
function because their blood supply is poor and ineffective. 

At first the circulatory system will be affected and the symptoms 
of pulse changes, including irregularity of rhythm, rapidity and weakness 
will appear. Pallor or cyanosis may be present, depending on whether the 
systemic or pulmonary system is first affected; coldness of the extremities 
occurs as the result of a diminished blood supply to the limbs; oedema will 
arise as the result of inability of the venous system to convey its load of 
fluid back to the heart, and there is danger of bedsores, owing to di- 
minished blood supply to the skin. 

Symptoms which arise as a result of interference with the functioning of the 
respiratory system include dyspnoea, cyanosis, orthopnoea, cough and expectoration. 
There may be slight haemopysis and some degree of bronchitis may be 
present. In advanced disedte oedema of the lungs occurs. 

The symptoms associated with disorder of the dimentary tract include loss of 
appetite, nausea, indigestion, constipation, flatulence and vomiting. Disorder of 
digestion is also a cause of palpitation. 

As regards the excretory system, the amount of urine is usually 
diminished and it may contain a small quantity of albiunin. As the skin 
does not act ireely, owing to defective circulation and the consequent 
insuflicient supply eff blood, it becomes dry and parched and is liable to be 
injured by fiiction and pressure. The bowels are usually constipated; ineffective 
return of the venous blood fi*om the lower part of the intestine and rectum, 
owing to congestion of the liver, may give rise to coi^;estion of the veins 
of these parts and result in haemorrheads. 

Symptoms affecting the nervous ysten are headache, complaints of altera-^ 
tion of vision and noises in the ears, irritability'of temper, sleeplessness, night fears 
and, in serious cases, delirium. A rise of temperature will usually only occur 
when the cause of the heart disease is specific or infective in character, as 
in rheumatism and infective endocartutis. 



TRBATMXNT AND NURSING 


351 


TREATMENT AND NURSING 

The treatment of heart disease is usually divided under three 
heading —Test, diet and drugs. With the first two nurses will be 
primarily concerned, and in the application of all nursing measures it is 
therefore essential to bear in mind the need for absolute rest, and it 
should be remembered moreover that rest for the whole person, physical 
and mental, automatically provides rest also for the disordered heart. 

Type of bed. The bed shoidd be comfortable, the patient should be kept ade- 
quately warm and may have a hot water botde to his feet and a light blanket 
next to him; if the weight of the bedclothes is sufficient to cause discomfort 
they should be elevat<^ by means of a low bcdcradle. Some sisters advo- 
cate the use of a blanket bed. 

Position of patient. The position adopted must depend on the symptoms 
present; in acute heart disease it will be possible to nurse the patient 
recumbent; in chronic heart disease in which dyspnoea is present the 
patient will have to be supported in an erect sitting position. It is im- 
portant that support should be adequate, and that there should be no 
hollows or spaces permitted between pillows. The head should be sup- 
ported on a smcdl head cushion, and the arms should be placed on pillows 
at the sides of the patient so that he sits armchair fashion. 

Rest must be adequate, and a patient with severe heart disease should 
not be permitted to make any effort — he should be washed and fed, very 
gently moved, and carefully lifted when necessary, so that his muscles do 
not contract during the strain of movement. His locker should be out of 
reach, and he should be warned against raising his arms. 

Later, when improvement occurs and he is allowed to do things for him- 
self, his activities should be very carefully graduated; at first he might 
clean his teeth, and help to hold his feeding cup; next, he might wash his 
face and hands, and so on. It is important to count the patient's pulse be- 
fore any active movement is made, and it should be counted again after- 
wards; if the effort has been too severe the pulse will not return to its 
original rate. This should be used as a guide throughout. 

Sleep is necessary as it is the best form of rest, and yet no one sleeps as 
lightly or as badly as does a patient with heart disease. Nurses require to 
exercise great ingenuity in obtaining the best possible conditions to secure 
sleep for their patients, particularly with regard to maintaining their 
physical comfort; the correct degree of warmffi, the provision of a low, 
non-irritating light, the reassurance that someone is within call and will 
hear the slightest sound — all of these things need careful attention. 

Other factors which may induce rest for the heart include the perfect 
functioning, as far as it can be obtained, of the excretory oig^ans; the skin 
should be cared for and bedsores prevented; the bowels should be regulated to 
act once or twice a day, producing a soft solid stool, or even watery stook, 
in order to remove fluid from the body and also to ensure that any possi- 
bility of constipation is avoided, as the passing of a constipated stool is a 
S^cat physical strain. The emmnt of urine passed should be measured and 
compared with the intake of fluid, and the urine should be tested daily for 
albumin. Diuretics such as novurit may be employed, see below. 

Choi. It is usual to keep a four-hourly chart in cases of heart disease, not 
only as a record of the temperature but also to obtsdn a regular record of 



352 HEART AND ORGANS OF CIRCULATION 

the pulse; and, besides the rate, the volume, tension, regularity and rhythm 
should be very carefully noted and any changes rcportwi to the physician 
without delay. When t^ing the pulse very d^nite otaervations should be 
made of the expression of the patient’s face, for any manifestation of 
anxiety; of his eyes, for signs of fati^c; his lips, for pallor and cyanosis 
— and his genei^ colour should also be noted — thus ensuring proper 
observation of many important points. 

Diet. The main factors in the administration of diet in heart disease are 
that it should be light, and easily digested, and that the feedings should be 
regularly and frequently administered giving only small quantities at a 
time because the stomach lies in close relation to the heart, and if the 
stomach is filled to capacity, or even only moderately filled, the weakened 
heart may be embarrassed. 

In acute heart disease when the heart is failing, as in acute rheumatic car- 
ditis or endocarditis, only diluted milk feedings will be given. As improve- 
ment takes place, a light diet may be ordered. As a rule, protein and salt 
are limited, though a little protein such as white fish may be given, but 
the diet should consist mainly of well-cooked farinaceous foods. It should 
not be too fluid, particularly if oedema is present, and fluid is in all such 
cases best taken between rather than with meals. 

Drugs. Digitalis, strophanthus and quinidine are the drugs most 
commonly employed in the treatment of heart disease. 

Digitalis acts as a heart tonic, slowing and strengthening the ventricu- 
lar contractions and prolonging the period of rest or diastole. It is given 
six-hourly because it is absorbed slowly. 

Dosage: Digitalis folia, ^ to i f grains 

Tincture of digitalis, 5 to 1 5 minims 

Nativelle’s granules of dimtalin, or of a grain 

Cat unit tablets, one tablet is given for every 10 lb. of body weight 

Digoxin pre{)ared from digitalis latuUa, dose, 0*75 to 1*5 milligrammes. 

Larger doses are employed to effect digitalization at the commencement of 
treatment, and it is in these cases particularly that careful watch should 
be kept. 

In nursing certain precautions should be taken and the following observa- 
tions made. A patient having digitalis should be in bed, he should be 
warned against making any sudden or violent movements. When having 
large doses he should be kept on absolute rest. The ptdse should be noted 
for irregularities, coupling of the beats, and decrease in rate. A pulse below 
60 should be reported at once. The rate of the heart beat should be counted at 
the apex. 

The urine should be measured and the increase noted; digitalis is a 
diuretic, to produce diuresis may mean that the drug does not suit the 

patient. Decrease in the quantity of urine indicates digitalis poisoning. 

ffausea and vomiting may occur. 

Strophanthus is usually employed when digitalis is not well tolerated. 
Tincture of strophanthus 2-5 minims may be given or strophanthin dose 

to of a grain by the intramusculau: or intravenous route. 

Quinidine, one of the alkaloids of cinchona, is used principally in cases 
of auricular fibrillation. The dose is 3 to 10 grains; a test dose of 3 grains 



nUCATMENT AND NUMINO 353 

it pven in case the patient has an idiosyncrasy; if no symptoms of toxaemia 
arise an average dose of 5 to 6 grains is then given every three hours for 
several days. The drug only be continued if it suits the patient. 

In the nursing care it is important to keep the patient quite quiet in bed, 
on absolute rest if possible. Tlie bowels should be made to act regularly 
and effectively every day. He will usually complain of headache. Nausea, 
vomiting, abdominal discomfort and pain, and diarrhoea indicate toxae- 
mia, and in some cases the patient becomes very ill. An erythematous rash 
may develop. 

Drugs used In cardiac oedema. Mersalyl is an official and Esidorne, 
Neptal, J/ovasural, Novurit and Salyrgan are trade preparations of mercury 
employed as diurectics for the relief of oedema in cardiac failure. The 
urinary output may be increased, up to ten pints during the 24 hours 
following the administration of one of these preparations. The degree of 
dehydration produced by passing large quantities of urine may be accom- 
panied by fatigue and malaise, but these symptoms usually disappear 
after a day or two. 

Administration. The patient, if up and about, shovild go back to bed. He 
is given thirty grains of ammonium chloride every six hours for two days 
in order to make the urine acid. He is then given one of the mercurial 
preparations either by the intravenous or intramuscular route (Novurit 
IS sometimes given in the form of suppositories). The dose is repeated at 
weekly or fortnightly intervals as found necessary to keep the patient free 
from a serious degree of oedema. 


SUDDEN CARDIAC FAILURE OR SYNCOPE 

This is a complication which may arise in any case of acute or advanced 
chronic heart disease. The patient will feel faint and may collapse, his 
breathing vrill become difficult and shallow, his pulse rapid and irregular, 
his face pale, his lips pale and blue, and beads of perspiration will collect 
over the brow and face. 

This condition requires immediate treatment by the administration of car- 
diac stimulants including coramine and alcohol. In addition, hot fomen- 
tations may be applied over the region of the heart, and external heat ap- 
plied by means of not blankets, hot water bottles and an electric cradle. A 
hot rectal saline should abo be administered. Oxygen should be given. 


CARDIAC ASTHMA 

Cardiac asthma is a form of paroxysmal dyspnoea, simil^ in character to 
asthma, which occurs in heart disease. The patient is acutely distressed and 
unable to rest or sleep, as he is so fttxjuently disturbed by painfully dis- 
tressed breathing. 

Nursing. The nurse will do everything she can to secure the patient’s 
comfort in bed, and seeing, for instance, that he is adequately supported 
and w^ propped up with pillows, she will constantly administer oxygen 
which wifi be found to give slight relief. Stimulants will be given com- 
paratively freely, and the nurse will be on the look-out for the signs of 



354 HEART AND ORGANS OF CIRCULATION 

fatigue which indicate the necessity for administering these. In most cases 
reli^ is oidy obtained after the administration of morphia. The prognosis 
is grave. 

ANGINA PECTORIS 

Angina pectoris may be due to interference with the nutrition of the 
cardiac muscle, owing either to degenerative changes in the vessels supply- 
ing the heart, or to impairment of the heart muscle. 

The symptoms include pain, which characteristically commences over the 
region of the heart and radiates down the left arm. The patient has a sense 
of tightness about the chest, and he becomes rigid as he feels that he is in 
danger of immediate death. His face becomes ashen grey and his skin cold 
and clammy. The pulse may vary, and in many cases the blood pressure is 
raised during an attack. Each attack begins suddenly, and it is usually 
brought on by exertion. (Sec also coronary thrombosis, below.) 

Nursing treatment during an attack. Nurses must be familiar with the drusp 
which may be ordered in the treatment of angina, and be able to apply 
them without delay. In some cases amyl nitrite is inhaled from minute 
glass capsules, the capsule being broken in a piece of gauze or a handker- 
chief and held under the nostrils. In other cases chloroform is inhaled from 
a piece of absorbent material; in others again, some form of nitroglycerine 
is administered in tablet form. 

The patient should rest whenever the attack occurs; if he is standing in 
the street he should keep still and be supported as well as possible, but if 
he is at home he should sit down and be comfortably supported. It is in- 
advisable for him to lie flat as, owing to the constriction of the chest, he 
feels he cannot breathe. 

Between attacks great attention should be paid to the maintenance of a 
good tone of gener^ health, constipation must be avoided, and a nourish- 
ing, easily digested, diet taken. A reasonable amount of sleep is necessary, 
and all strain and worry should be avoided. 

CORONARY THROMBOSIS AND CORONARY EMBOLISM 

Cardiac infarction may be brought about by coronary thrombosis or em- 
bolism. The former is commonly due to atheroma of the coronary vessels 
and the latter occurs as a complication in infective endocarditis. 

Symptoms. In some cases there wiU be a history of previous attacks 
of angina (see above), but unlike angina this attack usually occurs during 
rest. In a very acute case the patient complains of severe pain over the 
heart, radiating to the neck and arms and also over the abdomen; he 
may have nausea and vomiting. In appearance he may be grey or cyan- 
osed, his skin wilLbe covered with sweat and his breathing distressed. He is 
restless and anxious. 

The treatment of this form of cardiac attack is rest, morphia is adminis- 
tered and the patient is kept as quiet as possible; he should be confined to 
bed. 

DISEASES OF THE BLOOD VESSELS 

Aneuiysm. An aneurysm is a dilatation of the walls of an artery. It is 
frequently associated with degenerative chaiwa in the widls of the vessels 
and the aorta is the vessel most commonly anected. 



DUBASES OF THE BI^OD VESSELS 355 

In anevirysm of the aorta, the syn^toms produced are those due to pres- 
sure on the neighbouring organs-^yspnoea, cough and sputum will result 
from pressure on the trachea — d)^pha|^a -v^ be due to pressure on the 
oesophagus — congestion in the veins of the head and neck will be due to 
pressure on the large veins returning the blood to the heart — & brassy- 
cough is produced by pressure on the laryngeal nerves. In cases of aneu- 
rysm of the innominate or cither of the subclavian arteries there may be 
inequality of the two radial pulses, as the blood takes a little longer to 
flow past the dilatation, and the pulse on the affected side may be slightly 
delayed. 

Mursirtg and treatment. If admitted to hospital a patient with an aortic 
aneurysm is kept in bed in order to give him the necessary rest, and it will 
be important to see that he is not permitted to make any exertion. For a 
time he may be ordered absolute rest; later, he will be allowed to get up, 
and at this stage he should be warned against making vigorous movements. 

As in the nursing of all cases of heart disease, the bowels should be kept 
acting regularly, the skin should be cared for, the diet should be light and 
easily digested, the patient should be free from worry and anxiety and 
should get a reasonable amount of sleep. In some cases there is considerable 
pain, and morphia may be ordered for the relief of this; in other cases the 
pain is intermittent and angina is a feature of the condition. Other drugs 
ordered include potassium iodide, arsenic and mercury, and nurses should 
be familiar with any untoward symptoms that might develop after the 
prolonged administration of these. Necessary details will be found in the 
section on drugs, p. 293. 

Post-operative nursing care. In some cases of aneurysm surgical measures are 
taken. The aneurysm is separated from the vessel by proximal and distal 
ligature, which means that the circulation of the part, normally supplied 
by the vessel which has now been obliterated, has to be carried on by what 
is known as a collateral circulation — the vessels coming off above the area 
ligatured, anastomose with the capillaries of the vessels which arise from 
the artery below it; and, as when trafiic is diverted in the city when a 
street is put temporarily out of use for the purpose of repairs, so in this case 
the trafiic of the blood is permanently diverted into various side channels. 

The most important points in the post-operative nursing care of sucli 
a case include observation of the circulation of the limb or affected part 
together with the maintenance of all possible nursing measures for keeping 
the limb warm. This may be accomplished by means of an electric pad, 
an electric blanket, well protected rubber hot water bottles or the wrap- 
ping of the limb in warm wool. As sensation will be considerably im- 
paired, owing to the lowered functional activity of the circulation to the 
part, heat can only be applied with great care, ^d the affected parts 
should be inspected every fifteen minutes or so. The position of the affected 
limb should be adjusted in order to help the circulation of the blood in 
the limb and the movement of the venous blood in the vessels. 

Arteriosclerosis is a hardening of the wails of tlie arteries, which 
causes a loss of elasticity and is frec^uently associated with a reused blood 
pressure. Predisposition to this condition can be caused by a life of extreme 
tension and anxiety, and it is also brought on by chronic toxaemia, and is 
associated with such poisoning as that due to lead or the toxins of gout, 
syphilis and chronic interstiti^ nephritis. 



356 HEART AND ORGANS OF CIRCUtATION 

The sytr^ms are those of high blood pressure described in the note on 
P- 357 - 

Arteritis is inflammation of the walls of an artery. 

Atheroma is degeneration of the large arteries, such as the aorta, and 
is a common cause of aneurysm. 

Affections of the Veins. Phlebitis is inflammation of the vein 
wall; it may be associated with varicose veins, thrombosis (thrombo- 
phlebitis, see p. 554, is one type) or with gout and rheumatism. The 
affected vein becomes swollen and painful; in the case of a superficial vein 
the skin becomes congested, oedema frequently occurs in the region 
drained by the inflamed vein. 

Treatment is rest and the application of belladonna. The patient should 
stay in bed and have a non-stimulating though adequately nourishing 
diet; the bowels should be kept acting regularly. After six weeks, massage 
may be given to help restore the circulation; when the patient gets up an 
elastic bandage should at first be worn. 

Varicose veins are common in many people. The condition tends to 
run in families. Predisposing causes include occupations which necessitate 
standing, injury to superficial veins and phlebitis and thrombosis. The 
veins most commonly affected are the internal and external saphenous, 
their tributaries, and the gluteal veins draining the back of the thigh. 

Treatment is by injection and ligation. The jiaticnt has a bath on the day of 
operation, the limb is shaved from ankle to groin. A local anaesthetic is 
injected and a small incision made over the vein under treatment, it is 
dissected out, double tied, divided, and some sclerosing agent, 10 c.c. of 
quinine and luethrane, for example, is injected into the distal end and the 
limb is strapped from the ankle upwards. After one week the 8tra|ming is 
removed, and the stitches arc taken out, the vein is examined and if neces- 
sary further injection of the lower parts of the vein made. In a few cases 
the patient is retained in hospital for a day or two, but he is not kept in 
bed as rest is thought topredispose to the formation of pulmonary embolism. 

Contraindications to injection treatment are pregnancy, extreme age, raised 
blood pressure, severe constitutional disease, and a history of phlebitis or 
thrombosis. 

Complications include fainting, urticaria which would surest an allergy 
to the substance employed, allergic shock and collapse, and excessive reac- 
tion characterized by ascending phlebitis. 

(Venous thrombosis is described on p. 647, and embolism on p. 376.) 

HIGH BLOOD PRESSURE 

(Hyperpiesis) 

The walls of the arteries are normally elastic, contracting and relaxing 
according to the pressure of blood contained in them, and the amount of 
pressure exerted by the blood is described as the blc^ prenure. This is 
estimated by means of a manometer (see p. 41). Normally, the pressure 
registered is described as being 100 plus the age of the subject; tli^ is the 
^stolic pressure, a systolic pressure above 140 being consider^ excesrive 
in persons under 50. The diastolic pressure is that found during the period 
of diastole, or cardiac rest phase. The normal diastolic pressure is foirfy 



HIGH BLOOD PRESSUKE 357 

constant at from 70 to 80. In some cases of high blood pressure of the hy- 
pertensive type, it may be constant at 100, but this is a 20 per cent, di^ 
ability. 

Symptoms of hyperpiesls. The blood pressure is high, in arterio-* 
sclerosis the artery is felt to be thick and tortuous under &e examining 
finger, arterial tension is high and the pulse volume also is fairly full. With 
this type there is a tendency to cramplike pains in the muscles, and in the 
precordial area which is suggestive of angina (see p. 354) . 

Other symptoms of hyperpiesis include headache, particularly frontal 
headache made worse on stooping and on ocerlion. 

Fullness suid throbbing of the veins of the neck, with palpitation and 
some dyspnoea, on exertion. 

Giddiness, nausea and vomiting. 

Flatulence, indigestion and constipation. 

Nervous depression, and in some cases there are complaints of visual 
symptoms such as seeing spots of different colours, or blackness before the 
eyes. 

. There is a tendency to bleedings including epistaxis, haematemesis and 
cerebral haemorrhage; and also to retinal haemorrhage and profuse men- 
strual loss. 

Danger. The danger of high blood pressure, particularly when associated 
with arteriosclerosis, is that the disease is likely to be progressive and that 
the heart being overworked in order to maintain the circulation will even- 
tually, sooner or later, suffer strain and become disabled in consequence. 
This condition is described as a hypertensive heart; the heart is enlarged, 
and the apex beat can usually be felt i or 1 1 inches outside the normal line. 

As decompensation is now present, which means that the heart is failing 
to compensate for the general circulatory disability, the diastolic pressure 
will be raised in addition to the systolic pressure. All hypertensive cardiac 
cases arc liable to the further danger of cerebral haemorrhage. The grey 
matter is soft, and the hardened arteries passing through it receive very 
little support and, being d^enerated, they may rupture, and any exertion 
may increase the likelihood of this. Another danger is that of cerebral 



/Ot03O4O5O 60 7Oeo ieon 
■» Marmal Hyperpinis 

Fio. 169. — Svsrouc Blood Prusukr Graph in thb Normal Person and in a case 

OF Hyperpieso. 




358 HEART AND ORGANS OF CaRGULATION 

thrombosis, since blood may clot in the narrow d(^;enerated vessels through 
which it can only ptass slowly. 

Treatment. Before treatment is undertaken various clinical tests will 
be carried out in order to determine as far as possible the cause of the con- 
dition. In addition to the physical examination of the chest the urinary 
function will be investigated, the urine will be tested for the presence of 
albumin, the quantity passed will be carefully noted and the blood urea 
content determined. A cardiograph will be taken in ordo* to determine the 
regularity of the heart’s action and, if any hyperthyroidism is suspected, a 
basal metabolic test will be carried out. 

The principal points in treatment are rest, and diet. At the outset the 
patient may be kept in bed until the blood pressure becomes stabiliaed. 
In all cases the patient should be encouraged to lead a quiet uneventful 
life, avoid fatigue, retire early and rise late, rest at very definite intervak 
during the day and have one day’s complete rest in bed each week. 

The diet should be reasonably reduced; it is inadvisable for patients 
with high blood pressure to maintain their weight at a normal level and 
it should be reasonably below this. Articles of diet which tend to produce 
obesity should therefore be as far as possible eliminated. Red meat should 
only be allowed once a week; fish, eggs and chicken may be taken, but 
the patient may have large quantities of firesh firuit and vegetables; condi- 
ments should taken sparingly, alcohol as far as possible omitted, and 
stimulating drinks such as coffee and tea used only in very limited quanti- 
ties. Smoking is generally considered inadvisable. 

Another aim in treatment is to maintain the body fluids at a reasonably 
low level. For this purpose fluid may be restricted to two or three pints a 
day. The bowels should be kept acting regularly and, as it is often con- 
sidered ideal for the patient to have at least two fluid stools a day, this 
may be effected by means of a dose of calomel taken every week and a 
smsill dose of mr^esium sulphate daily. 

In fypertensive cases of heart disease, lowering of the body fluids is even 
more necessary, and these cases are usually given a rectal lavage of hyper- 
tonic saline, either common salt or magnesium sulphate being used. A 35 
per cent, solution is employed. It is very important to see that the concen- 
tration does not exceed this, as a higher concentration is found to be very 
irritating to the rectum. In addition, particularly when magnesium sul- 
phate is used, a small quantity of the solution, four to six ounces, should 
be retained for as long as the patient can manage it. This results in a large 
soft solid stool which may be followed by one or two fluid stools. The nurse 
in attendance should see that the patient does not suffer undue pain, and 
if tenesmus is produced she should report this to the doctor. In serious 
cases this treatment is carried out daily and in less serious cases twice or 
even once a week will be found sufficient. 

LOW BLOOD PRESSURE 

(Hypqpusis) 

A systolic pressure below 1 10 is considered abnormally low. Low blood 
prcMure is met with in Addison’s disease of the suprarenal glands, in con- 
ditions of chronic wasting and in myxoed«na. It also occurs in conditions 
of shock and bleeding when it is treated by applications of warmth and the 
administration of fluid. 



LOW BLOOD PRESSURE 359 

Patients with low blood pressure are usually anaemic and feel the cold 
very much, the pulse is soft and of low volume, they are weak and avoid 
exerting themselves and often feel faint and dizzy. 

Treatment. If immediate treatment is necessary, to relieve an attack 
of faintness or dizziness, adrenalin is usually ordered. The general treatment 
includes rest, a liberal easily digested nourishing diet, plenty of fluids, and 
treatment for the relief of anaemia. 

DISEASES OF THE BLOOD 

Abnormal variation in the quality or in the quantity of the blood con- 
stitutes a disease of the blood. The term anaemia indicates alteration in the 
size of the red cells and their haemoglobin content. Formerly the anaemias 
were described as primeary when little, if anything, was known of the cause; 
and secondary when the anaemia followed some known condition, such as 
continued bleeding for example. More recently anaemia has been classi- 
fied according to the size and haemoglobin content of the red blood cells. 
The following is after Wintrobe’s classification: 

(1) Macrocytic anaemia, in which the red cells are larger than nor- 
mal. This type occurs in pernicious anaemia. 

(2) Normocytic anaemia, in which the red cells retain their normal 
size, as in anaemia after severe haemorrhage and in aplastic anaemia. 

In the two next classes the words microrytic — small cells, and hypo~ 

chromic — having a decreased haemoglobin content, appear. 

(3 ) Simple microcytic anaemia, in which the red cells are small and 
the haemoglobin content little, if at all decreased, is seen in chronic infec- 
tions and carcinoma. 

(4) Microcytic hypochromic anaemia. The cells are small and the 
haemoglobin content is decreased. This typ)e is seen in chlorosis (see below) 
and in cases where bleeding is constant and chronic. 

The importance of this classification is that in the macrocytic anaemias, 
when the red cells have their normal haemoglobin content, the cases are 
benefited by liver; but in the microcytic hypochromic anaemias, where the 
haemoglobin content is diminished, iron is indicated. 

Primary anaemia or chlorosis, which is rarely seen today, was 
formerly fairly common amongst girls in their teens, and is characterized 
by a greenish-yellow complexion, indigestion, loss of appetite, constipa- 
tion, palpitation, difficulty of breathing — especially on effort — headache, 
swelling of the feet and ankles towards evening and some degree of in- 
somnia. On examination of the blood the number of red cells is found to 
be very low and the percentage of haemoglobin, instead of being from 95 
to 100 may be as low as fi-om 25 to 30 per cent. The blood is watery in 
apprarance and the colour index low. 

This type of anaemia responds rapidly to treatment. Reasonable rest is advis- 
able, wi^ good nourishing diet; fresh air is beneficial, and tonics contain- 
ing iron and arsenic produce rapid improvement; aperients may be neces- 
sary for the treatment of constipation at the outset, but the bowel should 
be regulated by the use of ftesh fhiit, vegetables and an adequate amoxmt 
of water, as soon as possible. 



360 


HEAKT AND ORGANS OF CIRCULATION 


PERNICIOUS ANAEMIA 

Pernicious anaemia affects persons of middle age, and in this condition 
the colour is lemon or canary^yellow; it may be mistaken for jaundice, but 
the whites of the eyes are not yellow — ^instead, they stand out with a vivid 
bluish-whiteness, in contrast to the yellow skin. 

Symptoms. The symptoms common to all types of anaemia arc present 
— difficulty of breathing, palpitation, headache and general feelings of 
fatigue and weariness, loss of appetite and nausea, and swelling of feet 
and ankles occurs, particularly towards evening. 

Certain symptoms are^ in addition^ characteristic of pernicious anaemia. The 
colour of die skin has been mentioned; the symptoms of indigestion are 
more marked; the tongue is red and sore, ana there is often marked 
nausea, vomiting and diarrhoea. In many cases some degree of paralysis 
of the limbs may be present, due to subacute combined degeneration of 
the spinal cord which occurs in many advanced cases and is an early 
feature in a few instances. The disease is characterized by marked achlor- 
hydria, which may be responsible for the disordered digestion. 

Examination of the blood reveals a diminished number of red cells; those 
present may be deformed and may be larger than normal while some arc 
nucleated. The haemoglobin content of the blood is low, perhaps as low 
as from 40 to 50 per cent., this condition arising from the fact that there 
are so few red cells, though actually the amount of haemoglobin present in 
each cell is higher than normal. 

Treatment. The administration of liver, cither in the form of half a 
pound of raw liver each day — ^which is rarely employed nowadays — or as 
liver extract which may be administered by mouth, by intramuscular in- 
jection or in very severe cases by means of the intravenous route, has 
brought the prognosis of j>ernicious anaemia to such a standard that there 
is hope of permanent cure. A preparation of hog’s stomach called ventricu^ 
lin is employed as an alternative, and this is used because it is now con- 
sidered that a preparation of the stomach is just as valuable as liver, and 
that a hormone or similar substance is prepaid in the stomach and stored 
in the liver, and that it is this material or hormone which controls the 
formation of blood cells in the bone marrow. 

Hydrochloric acid is given in large doses in a dilute preparation in lemon 
or orange flavoured water, both before and during meals, in order to at- 
tempt to make up for the deficiency in the gastric secretions. It is very 
disagreeable and it is therefore sometimes difficult to get the patient to 
continue taking this — and yet, as it is very necessary, the patient must be 
encouraged to persevere with it. 

In the nursing care of severe cases of pernicious anaemia the patient, being list- 
less and anaemic, feels the cold severely and it is therefore necessary to 
keep him warmly clad and covered with light warm bedclothes. The pos- 
sibility of bedsores must be carefully guarded against. The mouth rcq^uircs 
to be cleaned, as it is often sore, and the tongue, which is red and shiny, 
must be kept moist. The loss of appetite is a difficult feature to overcome, 
and the patient has to be persuaded to take the hydrochloric acid which 
has previously been mentioned; if raw or cooked liver is given it riiould 
be made as appetizing as possible; all diet should be cardBiUy prcf^ued 
and nicely served. The symptoms of vomiting and of diarrhoea or consti- 



PERNICIOUS ANAEMIA 36 1 

pation call for relief, and the former increases the difficulty of feeding the 
patient. As a rule fat should be limited in the diet as it tends to deposit in 
the muscle of the heart. 

The many other troublesome symptoms that are present will require 
nursing attention as they arise, such as headache, general depression, 
faintness, marked malaise, sleeplessness and swelling of the feet and ankles. 
A severe case of anaemia therefore requires very similar nursing care to 
one of cardiac failure (see p. 350). 

Secondary anaemia, which presents the symptoms common to all 
forms of anaemia, as detailed on p. 360, may be due to one or more of 
a great many causes and, when severe, demands emergency treatment in 
the form of blood transfusion in order to give immediate relief. Subse- 
quently the treatment is by the administration of iron. 

Aplastic anaemia is due to an abnormal and probably degenerative 
condition of the marrow, which interferes with its function in producing 
red blood cells. These cases arc desperately serious; the anaemia is ex- 
treme and often complicated by jaundice, and in many cases there is a 
rise of temperature. 

Haemophilia is a disease of the blood in which there is inability to clot 
properly, so that subjects may bleed to death after a slight injury. It occurs 
more markedly in males than females, and although there is little informa- 
tion to hand regarding treatment, it is necessary to try and prevent the 
occurrence of injuries which will bleed. 

Purpura is a disease characterized by the occurrence of bleeding into 
the tissues, and it is thought to be induced by toxic conditions, so that one 
of the first considerations is the investigation of this possibility. It is also 
met in scurvy, in serious cases of scarlet fever and in smallpox. 

The grave anaemia which accompanies a serious state of purpura neces- 
sitates great care, carefully applied rest and the administration of blood 
transfusion. 

Polycythaemia, also known as erylhraemia. Osier's disease and 
Vaquez's disease, is an increase in the number of red blood cells. There is 
ovcractivity of the bone marrow, which manufactures red cells at a highly 
abnormal rate, and the spleen is enlarged. 

In this disease deep X-ray treatment, applied in this case to the long 
bones, is carried out. 

DISEASES AND CONDITIONS IN WHICH THE WHITE 
BLOOD CELLS ARE PRINCIPALLY AFFECTED 

Agranulocytic Angina or Agranulocytosis is a rapidly progressive 
disease characterized by marked diminution or loss of the granulocytes 
(polymorphonuclear leucocytes) in the blood. This condition is c^ed 
neuiropaenia. 

The disease may be idiopathic, that is of no known origin, or it may fol- 
low the use of certain dru^, notably amidopyrine, compounds of arsenic, 
and the sulphonamidcs. The condition of the patient is serious. Necrotic 
ulceration of the mucous membranes occurs, particularly of the mouth and 
throat. With the disappearance the protective leucocytes the micro- 
organisms act unhinder^, and the result is ulceration and destruction of 



362 HEART AND CIRCULATION OF ORGANS 

the mucous surfaces which spreads with alarming rapidity. The patient 
becomes rapidly prostrate and in many cases fatal agranulocytosis occurs. 

Splenic anaemia or Banti’s disease is characterized by marked 
enlai^;ement of the spleen, and by diminution in the number of white cells 
— leucopaerda — ^the red cells and haemoglobin being also diminished. The 
treatment of this condition is splenectomy. 

The condition of leucopaenia also occurs in pernicious anaemia and in 
influenza and typhoid fever. 

Leucocytosis or leukaemia, on the other hand, is a condition of 
increase in the number of white blood cells. There are different types of 
this disease, and some degree of leucocytosis occurs in most conditions of pro- 
longed suppuration or sepsis, as in the empyema following pneumonia. 

Lymphatic leukaemia is a condition in which there is a very large 
increase in the number of white cells, especially of the lymphocytes^ and 
enlargement of the lymphatic glands all over the body. Normally the 
lymphocytes number from 25 to 30 per cent, as compared with the white 
ceUs, but in this condition the number may be increased until they form 
90 per cent, of the total. This condition is very serious and the prognosis is 
grave; the disease may end fatally. Treatment by means of deep X-ray 
Sierapy has been employed, often with considerable success. 

Spleno-meduliary or myeloid leukaemia is characterized by 
marked enlargement of the spleen which may half fill the abdominal cav- 
ity; the bone marrow which is contained in the medullary cavity of the 
long bones is overactive, with the result that a large number of polymor^ 
phonuclear white cells are formed. The leucocytosis is marked, and this 
condition is also serious and the prognosis grave. 

The treatment adopted is X-ray therapy, and in some cases good remis- 
sion of the disease occurs. 

DISEASES OP THE LYMPHATIC SYSTEM 

The lymphatic system is part of the circulatory system, behaving, as it 
were, as the middleman, working between the tissues and the bloc^, and 
acting as a purifying agent which tries to prevent disease organisms or 
other poisonous products from reaching the blood from the tissues; but it 
is very likely, in conditions of disease, to become laden with dangerous 
waste matter, and this is demonstrated in conditions of lymphangitis and 
adenitis, when the lymphatic vessek and glands beccune inflamed, owing 
to the load of 8q>tic matter with which they have to deal in conditions of 
local sepsis, when the invading organisms are of a very virulent character. 

Other conditions in which this function is demonstrated, when the 
glands in particular suffer and themselves become the site of disease, are 
surgical tuberculosis and secondary carcinoma. 

Lymphangitis cn* inflammation of the lymphatic vessels is charac- 
terizol by the presence of red lines under the skin; these are the inflamed 
vessels and can be traced to the nearest gland which may also be affected 
(see also adenitis, below). The area around the inflamed lymj^tics is 
tender and swollen, and signs of gmeral constitutional disorder wul accom- 
pany the cmidition when severe. 



DISEASES OF THE LYMPHATIC SYSTEM 363 

Lymphangitis is due to septic infection within a certain area — it may be 
that the fociu of infection is in a septic finger or toe, and the lymphatics 
which drain this area will then be anected, 

The treatment of the condition is to investigate for and then to treat the 
underlying cause; appUcatipn) of heat, either fomentations or immersion 
in hot ba&, will help. When the condition is complicated by cellulitis it 
is necessary to incise and drain the infected area. The general care of the 
patient consists of the ordinary nursing attentions required in the treat- 
ment of a febrile and painful state. 

Adenitis is inflammation of the lymphatic glands, one gland or more 
being affected. As in lymphangitis, when due to the presence of a septic 
focus, the glands which drain ue area will be infected. In the upper l^b 
the fint lymphatic gland is at the front of the elbow; very important large 
groups of glands lie in the axilla and below the clavicle. In the lower limb 
the first groups are the popliteal glands, then come large groups of in- 
guinal glands at the region of the groin. Several groups of glands lie in 
the neck, and these drain the region of the mouth, nose and throat which 
are so f^quently affected by septic inflammatory conditions. 

Adenitis may be simple when the gland is inflamed, enlarged, tender, 
red and hot, but does not suppurate; suppurative adenitis occurs when the 
inflammatory lesion progresses to the formation of pus. Adenitis may also 
be tuberculous, or carcinomatous, and a form adenitis occurs in actinomycosis. 

The treatment of simple adenitis is local applications of heat such as fomen- 
tations and poultices: st^uralioe adenitis necessitates incision and drainage 
of the infected gland; in tuberculous adenitis it is usual to aspirate the fluid 
and in some cases applications of X rays and radium are employed. 

When adenitis is severe it will be accompanied by a rise of temperature 
and the symptoms which are associated with this, and it will demand the 
ordinary nuning care applicable to such a condition. 

Lymphadenoma, which is also called Hodgkin’s disease, is ’’charac- 
terized by a general enlargement of the lymphatic glands, affecting many 
or all of the glands; the spleen is enlarged and considerable anaemia is 
present. 

It is a progressive disease, the enlarged glands exerting pressure on the 
nerves adjacent to them and giving rise to pain; all the symptoms of 
anaemia are present and the patient becomes gradually worse. 

Treatment is directed to relieving the anaemia and improving the general 
health of the patient; in many instances the application of deep X rays 
and radium to certain groups of the enlarged glands gives good results and 
by this means remissions in the course the disease are possible. 



Chapter 23 

Diseases and Disorders of the Organs of Respiration 

Catarrhal conditions of the respiratory tract: phatyngUis, laryngitis, tracheitis and 
bronchitis — Emphysema — Bronchiectasis — Asthma — Pneumonia — Broncho-pneu- 
monia — Pleuri^ — Empyema — Haemoptysis — Pulmonary embolism 

Pulmoruay Tuberculosis is dealt with under Sanatorium Pfursing, ch. 31. 

D iseased conditions of the respiratory tract are commonly classifi^ 
according as the upper part is affected, as in the case of a cold in 
the head, or the lower parts as in capillary bronchitis. 

In catarrhal conditions the discomfort experienced is due to interference 
with the function of the air passages in breathing. In most cases of catarrh 
the early symptoms of pain and obstructed breathing are due to dryness 
and congestion of the mucous membrane lining the passages. In the early 
stages of bronchitis the cough present will be painful, dry and suppressed. 

In the later stages of catarrhal conditions the congested membrane 
secretes an excessive amount of mucus, the presence of which adds con- 
siderably to the discomfort in the case of a cold in the head, the running 
at the nose causing much inconvenience and soreness. In bronchitis, the 
increased secretion causes constant coughing in order to effect expulsion 
of the mucus filling the passages, and ^though this may be less painful 
than the dry suppressed cough of the early stage, the constant effort of 
coughing prevents rest and sleep and results in weariness and fatigue. 

Disease of the lungs is another matter. In pneumonia, for example, 
large areas of both lungs may be incapacitated, and this will result in 
dyspnoea, which may be attributed to two factors : 

(i) The loss of area of normally functioning lung tissue owing to congestion 
and consolidation of a large portion of the organs (the lesser factor), and 
(2) the greater factor, strata on the heart due to the inefficient oxygenation 
of the blo^ owing to the diminished respiratory area. This gives rise to 
dyspnoea and cyanosis and in severe cases will be followed by serious car- 
diac failure. 

A detailed description of the varieties of dyspnoea and cyanosis will be 
found in the observations Upon respiration on pp. 43-4. 

CATARRHAL CONDITIONS OF THE RESPIRATORY TRACT 

Catarrh is a general term used to describe inflammation of a mucous 
membrane; in a common cold, the upper respiratory passives are affected, 
giving rise to rhinitis, inflammation of the nasal mucous membrane, to 
pharyngitis, inflammation of the pharynx, and in some cases laryngitis is 
present. 

A common cold is characterized by two stages. In the first instance the 
parts feel uncomfortably dry and hot, the membrane is congested and the 
nasal passages obstructed. In the second stage, coryza — a watery discharge 
from the nose — is present, because by this time the inflammation has pro- 
gressed and the membrane is now secreting mucus very ficeely. At first this 

364 



CATARRHAL CONDITIONS 365 

secretion is thin and watery, but after a day or two it becomes thicker and 
muco*purulent in character, and as the days pass it becomes offensive and 
thick like pus; later, as the catarrhal condition abates, the secretion 
diminishes. 

The treatment of a common cold may be considered to be local and general. 
The local treatment consists in giving astringent inhalations in order to dim- 
inish the congestion in the early stages and relieve the obstruction; the 
use of steam mhalations will make breathing easier; the interior of the 
nasal cavities should be gently lubricated to keep them soft and free from 
cracks. Later, during the stage of severe coryza, the inhalations may be 
continued as congestion remains, and many proprietary articles are ob- 
tainable for use as nose snifis and inhalations. The margins of the nostrils 
should be kept dry and free from soreness. The discharge is infectious and 
it should therefore be received on paper handkerchiefs or old soft rags 
which can be burnt; when the patient insists on using ordinary handker- 
chiefs these should be disinfected before they are washed, or washed and 
boiled separately from those of the remainder of the household. 

General treatment consists in helping the skin to act and so improve the 
circulation; a hot bath, packing a patient up between hot blankets and hot 
water bottles; the giving of a warm drink, such as lemon or hot whisky and 
the administration of a diaphoretic and sedative drug — either aspirin or 
Dover’s powder, which contains opium and ipecacuanha — ^will help to en- 
sure a good night’s sleep and will also help the skin to act. 

Whenever possible — ^and it is a pity this plan is so rarely considered pos- 
sible — a patient during the first 3 or 4 days of having a cold in the head 
should stay in bed, partly for his own sake, in order to avoid the possibility 
of complications, but also for the sake of others, in order to avoid spreading 
the infection. If he can stay in bed, he may take an aperient on the second 
night, but otherwise the use of an aperient may only make him feel cold 
and uncomfortable and still further lower his resistance. 

The pain experienced in the bones of the face when suffering from a 
cold in the head is due to infection of the sinuses; some degree of infection 
occurs in every instance, and the use of inhalations will help to relieve this 
and may possibly prevent serious infection. 

When a person suffers from chronic colds, one following another in rapid 
succession, the cause should be investigated; it may be that the resistance 
of the patient to infection is lowered and that the use of a suitable vaccine 
vrill improve this. 

PHARYNGITIS 

Pharyngitis may be acute or chronic. A-CUte pharyngitis is usually 
associated with a common cold; it may, however, be present as a symptom 
of the onset of one of the infectious diseases, particularly measles and 
whooping cough. 

The catarrh follows the same course as that described in the case of a 
cold in the head; at first the throat feels dry, swallowing is frequent in an 
endeavour to moisten it, and relieve the desire to cough; the cough is dry 
and irritating. TTie membrane of the pharynx will appear swollen, red and 
congested. 

Tne treatment is very similar to that of a cold in the head, by the use of 
steam inhalations, and hot gargles will also help to relicw discomfort; the 
application of cold compresses to the fi'ont of the throat will sometimes be 



366 THB ORGANS OF RESPIRATION 

found to give relief. The general treatment advised in the case of a ccJd in 
the head can also be us^ here. 

Chronic pharyngitis may follow repeated attacks of acute inflamma- 
tion but it is more often brought on by the inhalation of irritating dust 
and fumes, and this may be associated with various trades; it may be due 
to the excessive use of tobacco, particularly cigarettes, or to excessive use 
of the voice. It may be associated with rheumatism or with the presence of 
a septic focus, loc^y, either septic tonsils or infected teeth. 

Inc symptoms present are similar to those of acute pharyngitis; in many 
instances the throat is found to be relaxed and the uvula long and flabby, 
the latter touching the walls of the pharynx and causing constant coughing. 

The treatment of chronic pharyngitis is primarily to investigate and treat any 
existing cause and to improve the general health. In the meantime the 
symptoms and discomfort must be relieved by the use of paints and gar- 
gles, which may be either antiseptic and astringent, or stimulating in 
character. The use of potassium chlorate, which may be employed locally 
as lozenges or given as a medicine, will help to keep the parts clean as this 
drug is excreted through the salivary glands and therefore forms a con- 
stant local application in the saliva which is being swallowed. 


LARYNGITIS 

Laryngitis may be catarrhal or it may be specific, as are the tuber- 
culous and diphtheritic varieties. 

Acute catarrhal laryngitis is usually due to spread of infection 
from a cold in the head; it may, however, be due to inhaling irritating 
particles, to overstraining the voice, or to excessive smoking; it is also 
associated with influenza, measles and whooping cough. 

The structures of the larynx are inflamed, there is loss of voice, an irri- 
tating cough and retrosternal soreness. These symptoms are accompanied 
by malaise and the patient may have a slight rise of temperature; he finds 
it difficult to sleep as the cough is particularly troublesome at night. 

The treatment is rest of the voice, which is the only way of resting the 
larynx; if the temp>erature is raised the patient should stay in bed, and in 
all cases it is advisable for him to avoid changes of atmosphere as changing 
from a warmer to a cooler one, or vice versa, will cause an attack of cough- 
ing. Movement will also set up coughing, so that the patient should rest 
quietly, if he will. It is important for the reason given above that the tem- 
perature of the room in which the patient is nursed should be kept even, 
day and night. 

Local treatment by means of spraying the throat with a sedative substance, 
and steam inhalations which moisten the air inhaled, will give relief; ex- 
ternal applications of heat or moist warm compresses may help, and in 
some cases counterirritation is found to be of value. 

TRACHEITIS 

Inflammation of the trachea may be acute or chronic, and is usually 
associated with either laryngitis or loonchitis. 

Acute tracheitis often begins as a cold in the head, but the symptoms 
soon ritow that the trachea is affected; there is a hard, dry, painful and 



TRAOHEITIB 367 

initatii^; coiigh, accompanied by marked retrostenud soreness and pain; 
when the condition spreads to the larynx there is loss of voice. The cough 
is stimulated by movement and chmige of temperature, and is particulariy 
irritating and troublesome at night when the patient is unable to sleep 
very much. 

Tnatmmt, It is necessary to keep a patient with tracheitis in bed. The 
trachea is a large respiratory vessel, very near the bronchi, and the condi- 
tion may spread and give rise to a serious attack of bronchitis or broncho- 
pneumonia if this precaution is not taken, and subjects with trachritis are 
moreover usually middle-aged or elderly persons in whom constant cough- 
ing and loss of deep may soon give rise to cardiac strain. 

The patient should be carefully watched for signs of more serious in- 
flammation in the chest, a careful record of his temperature, pulse and 
respiration being kept; he may be given an aperient at the outset, and the 
physician will usually order a sedative to induce sleep. As the cough is 
dry and irritating sedative linctus will be required to relieve this; the diet 
should be light but nourishing, and the patient should have a jug of lemon- 
ade or any other drink he fancies at his side, as taking small drinks con- 
stantly will help to relieve the irritation which is making him cough. 

The front of the chest may be rubbed with camphorated oil and covered 
with warm wool; poultices, if applied frequently, will give relief, and anti- 
phlogistine is an alternative, though not as comfortable as the former. 

BRONCHITIS 

Inflammation of the bronchial tubes is described as primary when it 
occurs as the first symptom, and secondary when it is the result of spread of 
inflammation from the larynx or other part of the upper portion of the 
respiratory tract. It also frequently arises as a complication of influenza, 
measles and whooping cough. 

Bronchitis may be mild, severe or very severe, and it may be acute or ckrorric. 
When it affects the small tubes it is called capillary bronchitis (see broncho- 
pneumonia, p. 373), this type being most commonly met with in infants. 
When affecting the large tubes it is described as trackeo-bronchitis, which is 
the type most commonly met with in elderly persons. 

Bronchitis In elderly persons usually begins as a cold in the head 
and spreads to the large tubes giving rbe to a troublesome cough which is 
dry at first. At this stage the sputum is scanty and mucoid, but later it 
becomes more abundant and muco-purulent in character and the cough 
becomes looser. Slight pyrexia usually accompanies malaise and the res- 
pirations are increased. The patient complains of soreness and pain behind 
the stemtun and of slight dyspnoea. In extreme cases the dyspnoea is 
marked and it is then accompanied by cyanosis. 

Traainunt and nursing. The patient u kept in bed in a warm room (about 
65° F.). The diet should be light and nourishing, and the bowels should 
be kept acting regularly. Sedatives may be necessary in order that the 
patient may ueep, as elderly people who do not sleep become very ex- 
hausted. Expectorants wili be ordered. Local treatment, either rubbing the 
chest with liniment or applications of poultices or antiphlogistine may be 
ordered, and in some cases dry cupping is employed. 

The use ((f steam inhalations will do much to ndieve the dry harsh cough 
which is so distressing to the patient in the early stages of the disease. 



368 THE ORGANS OF RESPIRATION 

These may be administered either by means of a Ndson’s inhaler or by 
the use of a steam tent; in the latter case the patient is nursed under a 
canopy arran^d at the head of the bed. 

Chronic bronchitis. A form of bronchitis which occurs in some elderly 
persons winter after winter, and improves during the summer months, is 
described as wmter cougk. Such patients will be foimd in the chronic wards 
of hospitals year after year. The condition is commonly associated with 
other constitutional diseases, including diseases of the heairt and kidneys. 

The symptom include cough, which is very troublesome at night, a large 
amoimt of muco-purulent expectoration is brought up and there is a vary- 
ing degree of dyspnoea and cyanosis. There is usually slight fever. The 
ptdse rate is slightly increased and the respirations are also increased; con- 
stipation is present, while the urine is scanty and high coloured and 
deposits urates on standing. 

In the nursing care and treatment, the patient is transferred whenever jxm- 
sible to a warm, dry climate. When nursed in hospital wards a warm room 
is necessary. The diet should be very nourishing with the addition of cod- 
liver oil. In some cases vaccine treatment is employed. Respiratory anti- 
septics are utilized and expectorants are usually ordered. The local appli- 
cations mentioned above are also employed here. 

It is in the complications of bronchitis that the seriousness of the condition is 
met. Empyema may occur, and the condition may also give rise to emphysema 
and bronchiectasis. 


EMPHYSEMA 

In emphysema the air sacs have become dilated because the elasticity of 
the tissue in their walls has degenerated. Expiration cannot therefore be 
completed and as air is retained in the dilated sacs they arc never com- 
pletely empty. As the result of this the chest is as always in a position of 
half expiration, and the epigastric angle is widened. Although this condi- 
tion'fircquently follows chronic bronchitis it may also be brought on by 
whooping cough or by any very strenuous occupation in whic^ forcible 
expiratory efforts arc made. 

The patient suffers from dyspnoea; he has intcrcurrent attacks of bron- 
chitis and eventually his heart becomes disabled, and when this happens 
he is dyspnoeic even when^at rest. The treatment aims at maintaining the 
general health. 


BRONGHIEGTASI S 

Bronchiectasis is a dilated condition of the bronchi, with the formation 
of cavities which become filled with sputum. It occurs in patients in whom 
chrome coughing has weakened and dilated the walls of the air sacs, and 
is a complication of chronic pulmonary tuberculosis and chronic bron- 
chitis. (For X-ray examination see illustration, fig. 73, p. 183.) 

The symptom include cough, which is paroxyunal in occurrence. Quite 
firequendy attacks of coughing occur in me morning, smd also diuit^; the 
day after intervals of rest. The sputum is offensive in odour, copious in 
quantity, dark in colour and depouts in three layers — a layer of pus at the 
bottom of the gl^, then some brownish fluid surmounted by froth. As the 
result of absorption of toxins, the patient’s general condition becomes poOT, 



BRONOH1EOTA8I8 3^9 

the temperature is intermittent in character and he looks toxic and, as 
the years progress, he becomes ve^ wasted. 

Tne nursing treatment aims at maintaining the resistance of the patient by 
means of a good diet. It is important that he should be placed in a suitable 
position, i.c. head downwards for the purpose of drainage of sputum during 
and after the attacks of coughing (see postural drainage, p. 89). Disin- 
fectant inhalations are employed. 

A treatment which has been foimd of value in these cases is collapse of the 
lung, which has been carried out by means of avulsion of the phrenic 
nerve and by artificial pneumothorax. 


ASTHMA 

In asthma the patient sufters fi'om attacks of expiratory dyspnoea which 
are brought on as the result of spasm of the muscle in the walls of the small 
bronchial vessels. There are various causes of asthma — ^in many cases an 
attack is provoked by inhaling some foreign protein, in others it is provoked 
by the taking of some vegetable protein as food, but in many instances the 
cause cannot be determined. 

In a typical case the patient may have some discomfort which indi- 
cates that the attack is coming on. In other cases he wakens out of a com- 
fortable night’s sleep and immediately enters upon an attack. He sits up 
suffocating, almost unable to breathe, and his breath comes in wheezy 
laboured gasps, his face expresses fear, he is pale and anxious, his extremi- 
ties become cold and cyanosed, although his pulse and temperature may 
not change. After a varying time he be^ns to cough in short severe par- 
oxysms, which increase and eventually culminate in one which leaves the 
patient shaken to pieces and almost prostrated with fear and physical dis- 
comfort. He then expectorates a little very sticky mucus and falls back ex- 
hausted — but usually relieved. 

In some instances the attacks occur with little remission, and the patient 
becomes the subject of chronic asthma. 

Treatment. During an attack such as that described above, the treat- 
ment aimed at is immediate relief, which in many cases can be obtained 
by the administration of i to 8 minims of adrenalin; but, as this has to be 
administered hypodermically it becomes inconvenient for general use by 
the patient himself, and a Chinese drug, ephedrin, which in many cases is 
equally effective, is given as an alternative in half-grain doses by mouth. 
In very severe attach some physicians consider a dose of morphia useful, 
but there is a dsmger in this as the patient may become dependent upon 
the drug. 

The general health of any patient who suffers from asthma should be 
maintained at as high a level as possible. He should particularly avoid 
heavy meals at night and any food which he finds it difficult to digest. It 
is advisable for hun to sleep supported on several pillows. The bowels 
should never be constipated, and the hygiene of the nose and mouth should 
be very carefully attended to. Some patients find certain climates or atmos- 
pheres induce attacks whereas they can be quite comfortable in other con- 
ditions, even in the immediate neighbourhood. This is a point for their 
own consideration as regards the choice of their mode of life. 



370 


THE ORGANS OR RESPIRATION 


PNEUMONIA 

A classification of pneumonia is difiScult as so many cases are atypical 
and all cases have their classical symptoms obscured by the recent develop* 
ments in the treatment of pneumonia by sulphonamide drugs. M & 
B 693 has revolutionized the treatment of pneumonia, but it must never 
be/orgotten that the patient still requires rest and good nursing in order 
to regain his normal state of health as quickly as possible. Pneumonia may 
be considered in the following groups: 

Acute lobar pneumonia characterized by consolidation of one or more lobes 
of the lung. This is usually due to the diplococcus pneumoniae (pneumococcus) 
though it can be caused by other organisms. A great many types have been 
described but the majority of cases are due to types I and II. 

Acute broncho-pneumonia is a group which occurs mostly in infants and as 
a secondary broncho-pneumonia in elderly persons. 

Secondary pneumonia may occur as an acute pneumonia secondary to some 
other inflanunatory condition in the lung, such as a pulmonary infarct, a 
growth, or to a lesion set up by the occlusion of a bronchial vessel, and 
to these ca.ses the descriptive term ‘pneumonitis’ is sometimes given. 

Traumatic pneumonia, post-operative pneumonia, inhalation pneumorda and hypo- 
static pneumonia arc terms used to designate pneumonia secondary to some 
definite state or condition. 

The symptoms of lobar pneumonia are characteristic. The onset is 
sudden, with headache and a rise in temperature and increased pulse and 
respiration, the temperature being 103° F. or over, and the respirations 
as many as from 40 to 50. The patient is flushed, with bright eyes, anxious 
facial expression, a dry dirty tongue, a hot skin; he finds breathing very 
difficult, and is troubled by a short dry cough which he tries to suppress 
as every movement causes pain, and each act of respiration terminates in 
a typic^ expiratory grunt. 

The disease is character^ed by a very marked toxaemia ; it is a short shaup ill- 
ness, causing great strain on the heart, and it is this danger of heart failure 
that has to be ever borne in mind by the nurse who must be always on the 
look-out for symptoms similar to those described in an attack of syncope 
on P- 353 - 

Treatment and nursing. The aim of treatment is to maintain the 
patient’s strength so that the work of the heart is suppiorted, and to relieve 
toxaemia and prevent complications. On admission the patient will be put 
into a comfortable bed, and whether he is given one, two or three pillows 
will depend upon the degree of dyspnoea present. 

Felton’s cmcentraled serum in doses of 50,000 to 150,000 units is employed, 
particularly in types i and 2. 

For treatment of cases by M & B 693, see pp. 32&-g. 

Cheat. The temperature, puke and respirations should be taken and 
charted four-hourly. Particidar observation should be made of the pulse 
and respirations — the latter will be laboured and difficult throughout, but 
the pulM, if the heart is compensating, will maintain a fairly go<m vtfiume, 
and be regular and not too rapid. Decrease in the volume and any rapidity, 
say above 1 10 in the first few days, and over 1 20 after the third day, wouki 
be considered untoward. At the time of taking the pulse the nurse should 



PNEUMOKIA 


371 

make careful observation of the patient’s general condition, noting his 
colour — -pallor, greyness or cyanosis — ^the expression of his face for fatigue, 
his skin tor the presence of cold sweat, his nose for any signs of dilatation 
of the alae nasi, and his mental faculties for any tendency to wandering or 
delirium. She must also observe his sputum, note when it becomes tena- 
cious, rusty or mucoid, and whether it is copious or scanty. 

During the course of the illness the principal nursing duties include the 
maintenance of rest for the patient. It is important that he be saved all 
effort — he must not do anything for himself, he must be fed and washed 
and the sputum cup must be held for him. His mouth should be kept very 
carefully cleaned, all sordes being removed, and cracks and fissures treated 
in order to heal them. His lips should be kept constantly moist and lubri- 
cated with an oily preparation such as liquid paraffin. His nose requires 
similar attention as the nasal cavities tend to dry and become filled with 
crusts, which should first be lubricated and then removed. 

The position of the patient in bed should be carefully considered, and what- 
ever position is adopted should be adequately maintained so that he is 
entirely supported. He should be moved at intervals to avoid discomfort. 
He will frequently be found to lie on the affected side, and the nurse must 
be careful when she turns him on to the sound side as this will embarrass 
the movements of the diest and therefore diminish the work of the sound 
lung and so cause further strain on the already overtaxed heart. 

The personal clothing should be of light woollen material which can be 
easily removed, and it should accordingly be made to open either at the 
back or front. Patients who are sitting up should have a gamgee jacket and 
a warm flannel bedjacket in addition. Patients who perspire a great deal 
might have a light blanket next to them. It is important, however, that the 
bedclothing should in all cases be light. Whenever there is any tendency to 
coldness of the extremities — indicating the onset of cardiac failure — exter- 
nal warmth should be applied and hot water bottles given or a small elec- 
tric cradle applied over the feet. 

7'he skin and excretory organs should be attended to; the skin may be hot 
and dry or there may be free perspiration; in the latter case the patient 
will require frequent change of garments as he must not be left lying in 
damp clothing. The pressure points should be treated in order to prevent 
sores. The urinary output should be measured and the urine tested for the 
presence of albumin; albuminuria may accompany the onset of the febrile 
state without being considered serious but, when it occurs later in the ill- 
ness, it may mean that the heart is failing. The boweb should be kept act- 
ing regularly, one or two soft solid stools a day being considered adequate. 
As the patient tends to be a dry, thirsty individual there is a natural ten- 
dency to constipation, and although the provision of adequate fluid may 
help to avoid this, in many instances aperients may have to be resorted to. 
It is usual, for example, to give the patient an aperient at the outset of the 
illness. Care should be taken in the choice of aperients, avoiding those in- 
clined to the production of flatus, such as salines, and others, apt to pro- 
duce stimulation of the involuntary muscle and so give rise to griping and 
pain, such as colocynth, should also be avoided. As far as possible only 
uucatives such as liquid paraffin and phenolphthalein should m employed. 

Sleep is all important m the treatment of pneumonia. The importance of 
rest has already been pointed out, and sleep is the ideal form of rest since 
during sleep not only are the muscles relaxed but the central nervous 



372 the organs of respiration 

system is at rest, external stimuli being temporarUy cut off. The nurse must 
do everything she possibly can to obtain sleep for her patient, and the note 
on insomnia on p. 338 suggests measures which might be carried out 
with this object in view. In many instances the physical discomfort is so 
great, despite adl the nurse can do, that sedative drugs will have to be 
ordered, those most commonly employed being pulv. ipecac, co. et opii, 
dose 10 grains (Dover’s powder), and paraldehyde, dose a-4 drachms, the 
latter being commonly given per rectum. 

The suitable diet in pneumonia is rather a controversial subject, some 
physicians considering that, as the illness is so short, the provision of ade- 
quate fluids such as water and lemonade, up to 6 or 8 pints, provided that 
6 to 8 ounces of glucose are administered each day, is sufficient. Others 
like the patient to have nourishing fluids — ^in this case three pints of 
nourishing fluid, including milk, Rsnger’s food and chicken broth are 
employed, and 3 to 4 pints of watery fluids are given in addition. The 
management of a fluid diet in a case of pneumonia might take the form of 
that described in the section on administration of a fluid diet under diet 
section (p. 270). 

Some degree of delirium occurs in a great many cases; it is to be expected 
in chronic alcoholics, and in these cases the doctor will usually order a 
stimulant from the beginning, in order to avoid the shock to the system 
which occurs when alcohol is suddenly discontinued. It is important in 
attending these cases with delirium that movements should not be res- 
trained more than is absolutely necessary, as such restraint increases the 
effort made by the patient and the principal aim in nursing all cases of 
pneumonia is to maintain rest. The note on p. 346, in which delirium 
is discussed, is a guide to the nurse in her management of such cases. 

Crisis. Reference to the chart shown on p. 35 will be an indication of 
the febrile course of the disease and its mode of termination — by crisis — 
which may be expected between the fifth and tenth days. In some in- 
stances a false crisis occurs twenty-four hours or so before the true crisis. 
A false crisis is unaccompanied by any abatement of symptoms or any de- 
crease in the rate of pulse and respirations. When the true crisis commences, 
the patient will be observed to be more comfortable, his cough easier, 
his sputum brought up with less effort, he will be inclined to sleep, and the 
temperature will be found to be declining fairly rapidly, dropping from 
104“ F. to normal in 6 or 8 hours. This rapid decline can only take place 
by loss of heat to the body, and the skin will be found to be acting freely. 
The nurse must watch for this, wipe the increasing pwrspiration from the 
skin and change the patient’s damp clothing, and apply external heat in 
the form of hot water botdes, or a hot bedcradle and warm blankets. She 
should press warm stimulating fluids and nourishing drinks on the patient 
at this stage of the illness. He may sleep whilst the tempierature is falling, 
but during this period he requires constantly watching and, since it is im- 
pjortant for the nurse to know the rate at which it is declining, his tempera- 
ture should be taken without disturbing him. The danger at this p>omt is 
of collapse. Any sign of greyness and pallor, or cyanosis, weakness of pulse, 
or sl^owness of breathing must be treated by cardiac stimulation — the 
^ysidan will order the stimulants which may be given in this emergency. 
The nurse should have ready, for the moment when the patient wakens, 
warm towels to rub him down, a warm bedgown to put on, and hot blan- 
kets to cover him. At the same time she should give him an opportunity to 



PNEUMONIA 373 

pass urine, which is more rapidly secreted at the time of the crisis, take his 
temperature and give him a warm stimulating drink and tuck him up 
when he will go to sleep again, and probably waken several hours later, 
thoroughly refreshed. Tne treatment which has just been described should 
then be repeated. 

After the crisis the patient remains in a very serious condition for some 
time, being now very weak after an extremely short sharp illness, and is 
still in considerable danger from cardiac failure and collapse. He should 
not be permitted any exertion for a further week, and any signs of cardiac 
failure such as cyanosis, pallor or pulse weakness should be observed and 
treated. 

At this time the amount of food may be suitably increased, the patient 
being gradually given a nourishing diet of high caloric value. After a week 
or ten days he may be p)ermitted to wash his face and hands, and effort 
should be gradually increased until he is allowed to perform his own toilet. 
He may then be propped up and allowed to read in bed. When he is per- 
mitted to get up, half an hour is considered quite long enough on the first 
day, and this may be increased to an hour on the second. Convalescence 
is fairly rapid and is not usually complicated, but a fairly long convales- 
cence, with rest from work and change of air, and a good liberal nourishing 
diet should be recommended. 

Infection and isolation. Primary lobar pneumonia is a notifiable 
fever under conditions of epidemic. The sputum is infectious and teeming 
with organisms, and requires disinfection before disposal. In nursing cases 
of pneiunonia in private houses, aU feeding utensib should be kept separate, 
the mutum should be disinfected before disposal, the patient’s handker- 
chief should be washed separately from those of the household, and the 
hands of attendants and visitors should be carefully washed after any con- 
tact with the patient. 

Complications. Pleurisy may be regarded as a complication although 
it occurs in all cases of pneiunonia when the inflammation spreads to the 
surface of the lung. Empyema may complicate convalescence. Other com- 
plications include heart disease, otitis media, nephritis, meningitis, mal- 
resolution of the lung and the formation of lung abscess. 

BRONCHO-PNEUMONIA 

Broncho-pneumonia is also described as capillary bronchitis and as 
catarrhal pneumonia; it is met as a primary msease due to infection of 
micro-organisms and as a secondary condition as a complication of 
measles, whooping cough, influenza, and it may also arise as the result of 
the inhalation or aspiration of vomi^ blood or s^va. 

Primary broncho-pneumonia is most often met with in infants. The 
infant is very ill, he is flushed and cyanosed, his temperature is high and 
continues for from 8 to lo days with ^ght daily remissions to terminate by 
crais or lysis. The respirations are rapid, from 50 to 60 per minute, there 
is marked and distressing dyspnoea, with movement of the alae nasi, re- 
traction of the sternum and recession of the intercostal muscles. The pulse 
is rapid, over 120, and becomes weak and running in character as the 
disease raogresses. There is a short dry cough, but no expectoration, as tiny 
infewM do not expectorate, usually swallowing any secretion brought up. 



374 the organs op respiration 

At first the infant is restless, but as the days pass and toxaemia increases he 
becomes drowsy. 

Treatment and Nursing. The infant should be in bed, propped up so 
that his head and shoulders are raised; he should be lifted for changing and 
feeding in order to get frequent changes of position. If secretion is brought 
up to the mouth, the nurse should endeavour to get it away so that it is 
not swallowed, l^pectorants are not luually given to tiny infants, but if 
the heart is in a go^ condition tincture of ipecacuanha is administered in 
doses which will effect vomiting in order to assist in the bringing up of 
sputum. 

The temperature of the room should be 65° F. and some physicians like 
a moist atmosphere — either a steam kettle boiling in the room, or a steam 
canopy may be provided. The chest should be rubbed with warm cam- 
phorated oil morning and evening and covered with wool or a gamgee 
jacket. The personal clothing should be light flannel and the infant pro- 
tected from chilling. 

The diet given is fluid, about 8 ounces of diluted milk containing 2 
drachms of lactose every 3 hours being adequate. If curds appear in the 
stools or vomiting occurs the milk should be citrated (see p. 266). The 
temperature, pulse and respiration should be recorded every four hours; 
if the fever reaches 105° F., the infant should be sponged, and inhalations 
of oxygen may cause improvement in colour and help to relieve the 
dyspnoea. The bowels should be kept acting regularly. 

A tiny child or infant who is very ill — as is this one — requires constant 
company and his cotside should not be left; the nurse should touch him 
gently, take hold of his little hiuid, stroke his brow, and in this way let 
him see he is loved and cared for, and this will help the contentment which 
is an aid to the rest that is so essential if this short sharp serious illness is to 
be brought to a successful termination. 


PLEURISY 

Inflammation of the pleura may be acute or chronic. Acute pleurisy ac- 
companies most cases of pneumonia. It is also common in pulmonary 
tuberculosis and may be one of the modes of onset of this disease. 

Two main varieties are described, dry pleurisy, in which the mem- 
brane is inflamed but there is no exudate, and the roughened fibrous mem- 
brane rubbing together gives rise to considerable pain. 

The lymptoms in this variety are a short sharp shooting pain, increased 
on movement of the chest, as on taking a deep breath or when the patient 
coughs. The cough is short, dry and suppressed, and the patient is unable 
to rest, unable to sleep because of his pain, his temperature is usually 
raised, his respirations rapid and shallow, and his pulse slightly quickened. 
He tends to lie on the affected side in order to limit the movements which 
ast giving him pain. 

The second variety is described as pleurisy with fusion, and in this 
type considerable fluid has been secreted and the two pleural membranes 
are separated. By means of this they are kept from rubbing togt^her and 
the pmn due to friction is not present. The presence of a quantity of fluid 
in the pleural cavity considerably embarrasses the breathing, however, and 
gives rise to dyspnoea. When there is respiratory distress present cyanosis 



PLEURISY 375 

occurs and, when there is a large (quantity of fluid, the heart may be dis> 
placed. The other symptoms mentioned in dry pleurisy, which are those 
associated with a rise in temperature, are also present. 

Treatment. A case of pleurisy is treated as a febrile case, the patient is 
kept in bed, given an aperient at the outset and a four-hourly record of 
the temperature, pulse and respiration rate is kept. 

In dfy pleuri^ some means may be taken to help immobilize the affected 
side such as the application of a tight binder, or strapping the chest; 
counterirritants may be ordered to relieve the pain, and either a form of 
heat such as antiphlogistine, or a mustard plaster may be used. Sedatives 
will usually be necessary to relieve the pain in order that the patient 
may sleep. 

In pleuri^ with effusion, if the fluid is embarrassing the action of the heart 
some of it will be removed. In many cases this condition persists for weeks 
and the fluid is gradually absorbed. 

In all cases of pleurisy the ordinary nursing measures employed in the nurs- 
ing of any febrile case are required, with, in addition, special care in each 
case. In dry pleurisy everything should be done to prevent pain, and in 
pleurisy with effusion the chief point to be considered will be relief of the 
embarrassed breathing by maintaining a suitable and comfortable sitting 
position in bed. 

EMPYEMA 

Empyema is a collection of pus in one or both pleural cavities. It may 
follow pleurisy, pneumonia or pulmonary tuberculosis. It is the complica- 
tion which would be suggested in any of these cases by a secondary rise in 
temperature following &e subsidence of the initial attack of the disease. 

Symptoms. The chief symptom is irregular and intermittent pyrexia, 
accompanied by an increase in the rate of pulse and re.spirations. As the 
fluid in the pleural cavity is pus, unless it is removed the patient will 
rapidly assume the appearance of one suffering from s^ticaemia. His 
skin will be grey, and unhealthy looking, his cheeks fltished, he will 
become wasted and considerable sweating will occur. The appetite will 
be lost and malaise will be marked. As a rule there is some pain in the 
side and a cough is present. When the fluid becomes large in quantity the 
action of the heart and lung will be embarrassed. 

Treatment. In all cases the chest will be explored and a specimen of 
pus examined, to discover the organism that is producing the condition. 
In cases in which pus-producing organisms are found, resection of rib 
will be carried out in order, by evacuating the cavity, to remove the danger 
of septicaemia. 

The post-operative nursing care is described under the heading of common 
surgical conditions on p. 671. 

HAEMOPTYSIS 

The spitting of blood occurs in a number of conditions but most par- 
ticularly in disease of the heart (mitral disease), and as a complication in 
pulmonary tuberculosis. 

A severe attack of haemopfysis is a very alarming condition, the patient 
sometimes coughing up a large quantity of blood. It is usually frothy. 



37^ the organs of respiration 

mixed with sputum amd bright red in colour, and if the reaction is tested 
it will be found to be alkaline. 

The first aid treatment is of primary importance in such a case, and 
the patient should be put to rest in a sitting position wherever the attack 
has occiured; his respiratory passages should be cleared of bloodclot by 
putting a finger at the back of the throat and clearing it out; he should 
then be given sips of cold water — he may wash his moudt out first, in order 
to avoid the nasty taste of blood, and then have a drink. His clothing 
should be loosened about the neck and chest and he should be allowed 
to breathe fresh air; he should at the same time be reassured ais he will be 
very terrified, and he must be warned to avoid any effort and even to 
suppress coughing as far as possible. 

As soon as possible he should be very carefully lifted into bed, but the 
effort of undressing him should not immediately be undertaken — he should 
rest for a time first. In the meantime, his pulse and colour should be very 
carefully noted, the degree of shock observed and treated as necessary. He 
may be given iced water by mouth, and the nurse should prepare a hypo- 
dermic injection of morphia as the physician will probably order this on 
arrival. He may also order various substances for the arrest of bleeding, 
such as preparations of calcium and coagulen ciba. 

Once the patient is comfortably in bed and undressed, he may be placed 
in a sitting position or, if the bleeding has been very severe and shock is 
present, it may be found necessary for him to lie down. Suspending an 
icebag over the affected side, if this is known, does much to reassure the 
patient, and it also helps to keep him lying quiedy, in order to preserve 
contact with the cold application. 

The nursing treatment during the days following a severe attack of 
haemoptysis is very similar to the nursing care of any patient who has bled 
seriously. Rest is essential, the diet should be low, cool and non-sdmulating, 
the bowels should be kept active by the use of saline aperients, and all 
movements and excitement, worry or anxiety should be prevented. The 
admission of visitors should be very carefully controlled and only those 
that will help to keep the patient calm, and not excite him, should be 
admitted. 


PULMONARY EMBOLISM 

An embolism is a foreign particle moving in the circulation, usually 
a small portion of bloodclot, and when it is circulating in the lungs it is 
described as a pulmonary embolism. It reaches the pulmonary circulation 
from the right side of the heart where it enters the pulmonary artery; the 
particle may have been brought to the heart by way of the venae cavae 
from some distant part, as when a pulmonary embolism occurs as a com- 
plication of some pelvic or abdominal operation; it may also be due to 
marked slowing of the circulation which happens in some forms of heart 
disease when bloodclot forms in the right aiuncle and is carried thence to 
the lungs. If the clot, or other particle, is big enough to obstruct a> large 
artery in the lung, instant death occurs; the patient may be found to 
have died without any apparent distress, or he may sit up, look grey, gasp 
for breath and fall back on his pillows dead. 

Symptoms. When the embolism blocks a smaller artery, only a por- 
tion of the lung will be deprived of blood, and the symptoms will then 



PULMONARY EMBOLISM 377 

dqjend on the extent of the area affected. The patient will sit up frightened, 
gasping in an effort to breathe, his colour will be grey and cyanosed and 
he may cough up some blood; he will complain of acute pain in his chest. 

Treatment and nursing. The first-aid or immediate treatment is im- 
portant, and this is usually carried out by a nurse, who must keep quite 
calm and not appear flurried while she reassures the patient, supporting 
him in a sitting position until she can maintain him in this position by 
means of pillows; she should advise him not to move and must loosen any 
tight bands of dothing round his neck and waist, open an adjacent 
window so that he gets plenty of air, give intranasal oxygen if it is avail- 
able, and press her hand against the patient’s side in an attempt to relieve 
the pain; she may apply a hot water bottle or some antiphlogistine or other 
hot application. She should hold the sputum cup for the patient, but must 
try not to let him see any blood he brings up; she may moisten his lips 
and give him small sips of water. She should prepare morphia which the 
physician will order when he arrives. 

Subsequent nursing measures aim at keeping the patient as quiet as possible 
and maintaining the blood pressure comparatively low; the physician will 
order sleeping draughts so that the patient sleeps at night, but the nurse 
should see that his days arc uneventful, visitors who might excite him not 
being admitted; he should not be allowed to read newspapers or exciting 
literature, his diet should be light, and it should be given cool; fluids 
ought to be limited to 3 pints; the bowels should be kept acting twice a 
day, by the use of saline aperients at first, and after the first week by means 
of liquid paraffin. 

A careful record of the temperature and pulse and respiration rate 
should be kept, and the patient’s colour should be noted. The portion of 
lung which has been deprived of its blood supply is not acting, and is 
called an infarct — if it is large, the degenerative changes which must of 
necessity follow may give rise to septic pneumonia. 

When embolectomy, or removal of the clot, is performed, it requires to 
be carried out immediately, but this operation has not been extensively 
used in this country. Instruments for this emergency are shown on p. 691. 



Chapter 24 

Diseases and Disorders of the Organs of Digestion 

Dyspepsia — Peptic ulcer — Haematemesis — In^ammaiory conditions of the alimen-- 
tasy tract — stomatitis^ gastritis^ enteritis^ cohtisy divertictdiHs and epidemic diar^ 
rh^a — Diarrhoea and constipation — Worms — Pyloric stenosis — Hirschsprung* s 
disease — Visceroptosis — Diseases of the liver and gallbladder— jaundice^ chde-^ 
cystitis y cirrhosis of liver, liver abscess, acute yellow atrophy 

T he idigj^tive tract extends from the mouth to the lower part of the 
small intestine; many substances enter it, and various parts of it 
secrete digestive and lubricating fluids which act on its contents, and 
the secretions of other organs are received by it, notably the salivary, pan- 
creatic and bile fluids. 

Loss of appetite, nausea, vomiting and indigestion are the symptoms commonly 
met with when the functions of this group of organs are impaired. The 
causes of disorder of digestion are manifold — the secretion of the digestive 
fluids is disorganized in all diseases associated with a rise in temperature, 
in diseases of the heart and circulation, and in many functional and organic 
nervous diseases. (The note on indigestion as a symptom of disease, on p. 
345, will suggest the number of diseases and conditions in which it may 
occur as a symptom.) 

Dyspepsia may be acute or chronic, and it may be mild, severe or very 
severe. In the mild forms the symptoms commonly met with include dis- 
comfort after meals, nausea, heartburn, dryness oi the mouth with thirst, 
a dirty flabby tongue, a disagreeable taste in the mouth with offensive 
breath, and in some instances salivation is increased. Nausea may con- 
tinue for days and be accompanied by headache, constipation and vomit- 
ing. 

When the condition is more severe, indigestion may be accompanied 
by a rise of temperature and a more marked degree of malaise, the 
patient feeling ill enough to remain in bed; the abdomen may be very 
tender, distended and painful, and the pain intermittent and colicky in 
character. 

The treatment of dyspepsia aims primarily at the relief of the symptoms; 
the cause should then be investigated and treated; a diet which is suitable 
for each individual case is ordered, any foods which irritate or give rise 
to symptoms of indigestion being studiously avoided. The general con- 
dition of the patient's health should be investigated and it should be 
maintained at a high level. Adequate fluid should be given, the bowels 
regulated, and the patient should endeavour to obtain a normal amount 
of rest, sleep, recreation and exercise. 

During an acute attack of indigestion it may be necessary to keep the patient 
in bed; when vomiting is persistent it will be necessary to omit fo^; but 
fluid starvation should be watched for (sec dehydration, p. 271.), and an 
adequate amount of fluid given, with some glucose added if possible. 

In chronic dyspepsia the patient often becomes so much afraid of the dis- 
tressing symptoms of the condition that he will not eat enough and con* 

37S 



THE OROANS OR DIGESTION 379 

sequently loses weight. He will then become anaemic and is in danger of 
developing an abnormally small appetite. 

In the medical tieatment of dyspepsia it is usual to examine the secre- 
tions and the functions of the stomach by means of test meals and X-ray 
investigation. The preparation for, and the manner of assisting at, a test 
meal is described on p. 215. 

PEPTIC ULCER 

The term peptic ulcer implies the presence of an ulcer on the parts of 
the stomach or duodenum which are exposed to the presence of the acid 
gastric juice. Whatever may be the cause of such a lesion, once present, 
constant contact with the gastric juice serves to keep it from healing and 
will probably cause it to spread. 

The symptoms of peptic ulcer are those of dyspepsia or indigestion; 
as a rule a patient has attacks of this, he is sometimes better and some- 
times worse, and usually notices that the attacks become more frequent — 
he then consults a doctor. The doctor proceeds to make a diagnosis, 
examines the general condition of the patient, takes his history, investi- 
gates the presence of pain and tenderness in the epigastrium and has the 
stomach contents examined by means of a test meal, and the movements 
of the stomach and duodenum investigated by means of a barium meal 
and X-ray examination. 

The symptoms vary slightly according to the position of the ulcer. 
In gastric ulcer pain is experienced near the cardiac end of the stomach, 
coming on very soon — about 20 minutes — after a meal, and may be 
relieved by taking sodium bicarbonate or by vomiting. The patient be- 
comes adraid to cat because of the pain he will suffer and consequently 
loses weight. 

In the case of duodenal ulcer the pain is to the right side rather than in 
the middle line; it docs not begin until some time has elapsed after taking 
food — in some cases not until about 2 hours after; the patient may say 
that he wakens with pain after he has been in bed for an hour or two. This 
pain is relieved by taking food or drink and a patient will often say that it is 
relieved by taking a glaw of milk and soda or a couple of biscuits. It is also 
relieved by alkahs. These patients do not lose weight as consistently as do 
those with gastric ulcer, as they are probably taking small frequent meals. 

On exiunination pain and tenderness will be found to be present over 
the region of the duodenum. 

The principles of treatment. The treatment of peptic ulcer is mainly 
dietetic. In addition, the principles of treatment include the provision 
of rest, by limiting the movement of the stomach and its functional 
activity; by avoiding large me^ and long spaces between meals, giving 
small liquid meals at short intervals of i J to 2 hours; providing substances 
such as belladonna before meals in order to reduce spasm and so allay 
irritability of the stomach and to inhibit the secretion of gastric juice. 
Olive oil is also employed as the oil inhibits the movement of the organ. 
Alkalis arc given between meals, in order to reduce the acidity of the 
contents of 3ie stomach, and if possible prevent acidity. 

CompltcatioilE. The complications of peptic ulcer include bleeding, 
which may be slight or severe; in some cases oozing of aanall quantities 



380 the organs of digestion 

of blood occurs, though the amount may be so slight that the presence of 
melaena in the stool is not obvious. In these cases a special test may be 
made and the nurse will be required to send a specimen of the stool to the 
laboratory for this purpose. (See special care in prq>aration of a patient 
for this, as noted on p. 69.) A small quantity of hidden blood, known as 
‘cocuW, is such as can only be discovered by careful examination and can- 
not be suspected by the naked eye. 

Melaena (altered blood) may be observed as black tarry stools. The blood 
may be imaltered when bleeding is rapid and severe, and the stools passed 
may be well coloured by the large quantity of blood in them. 

Haemalemesis is the vomiting of blood from the stomach, and when 
copious it may be very litde altered; but when the blood has remained 
even a short time in the stomach it becomes acted upon by the gastric 
juice and altered, and the characteristic appearance of this vomitea blood 
is described as being of coffee-grounds consistency and colour. 

Adhesions may form as the result of a long-continued inflammatory lesion 
in the vicinity of an ulcer or ulcers, and these may result in fastening the 
stomach or duodenum firmly to its adjacent structures, either to the liver, 
pancreas, colon or peritoneum. In such a case, movement of the organ 
will be limited and contraction may occur. 

Scarring md contraction. When an ulcer occurs on one wall of the stomach, 
the irritation set up tends to produce spasm, which results in contraction 
of the muscle fibres and approximation of the opposite wall, and in this 
way an ulcer on the stomach wall may set up a contraction sufficiently 
marked to divide the stomach into two chambers — an hourglass stomach. 
An ulcer at the pyloric end of the organ may result in stenmis, and give 
rise to a very dilated stomach. 

Fisttda. In some ca^ where the stomach has been firmly attached to 
the wall of another organ a communication (fistula) may be made between 
them. The commonest type of fistula occurs as an opening between 
stomach and colon — a gastro-colic fistula. 

Malignant disease may complicate peptic ulcer, but this rarely happens. 

Nursing Care. Many patients with p>eptic ulcer arc cheerful and 
optimistic; others, having suffered discomfort in the epigastrium, off and 
on, perhaps for many years, with the irksmneness of always having to con- 
sider what they may or may not eat, become introspective and fidgety; 
others develop some irritability of temper and many are thin, and feel 
the cold very much, and often feel generally out of sorts and miserable. 
The nurse must therefore be able to visualize the state of life that has 
brought about the mental attitude of any given patient to his surroundings, 
and be prepared to encourage and help him. 

The bed should be comfortable and the personal clothing warm, and 
as the patient will have to spend several months in bed in many instances, 
airy recreation he likes should, if possible, be provided. At first his diet 
will be limited to small quantities of fluids at regular intervals, and as 
far as she can the nurse should consider the patient’s taste as to whether he 
likes things hot or cold, and allow him to have any little flavouring he 
fancies, if permissible. His feedings should always be brought puncti^y 
and the empty vessel removed at once; it is apt to depress patients to have 
an empty feeding cup or glass left at the bedside, apart from being bad 
bedside technique. 



PEPTIC UJLOER 381 

Later, as the patient is allowed fuller diet, he should be encouraged to 
look forward with pleasure and without apprehensicm to the new dishes 
until the day comes when a poached egg may be allowed for breakfast. 

It is very important to encourage the patient to adhere exactly to his 
diet and to avoid eating anything that is not allowed, and to abstain 
from eating between his times for meals. Smoking is usually forbidden. 

The bowels should act regularly every day. A difficulty may be met 
here because the diet, at first, is so very limited, but to obviate this some 
physicians give their patients liquid paraffin, others order the adminis- 
tration of a small olive oil, or glycerine and plain water, enema daily. The 
alkalis the patient is taking vary slightly in type, in many instances the 
powder is a mixture of bismuth and magnesium carbonate. Bismuth tends 
to produce constipation, but magnesia counteracts this as it is a laxative; 
sometimes a patient may react to bismuth and become very constipated, 
in other cases he may be affected by magnesia and have diarrhoea; it is 
important therefore for the nurse to co-operate with the physician and 
endeavour to find whether, by altering the mixture in order to regulate 
the bowels, the use of aperients may not altogether be avoided, which is 
very desirable. 

Whilst a patient is on milk feedings his mouth will require care, the 
hygiene of the mouth being a very important point in the care of all 
cases of disorder of the digestive tract. The patient is often thin, and great 
care must therefore be exercised in the prevention of bedsores. 

When the patient begins to get up, this must be carried out carefully; 
he should be warmly dressed and lifted on to a couch at first; and should 
only be out of bed for half an hour; in a few days he may feel strong 
enough to stand by his bedside for a few moments and after ten days or 
so he may be permitted to walk a few steps. He has probably been ill 
for some time, and his muscles will be flabby, so that he will tire easily 
and should be encouraged to go very slowly; if allowed to get tired he 
will become depressed and discouraged, and this should never be per- 
mitted to happen. 

HAEMATEMESIS 

Haematemesis as a complication of peptic ulcer has already been referred 
to (see p. 380). A patient with a peptic ulcer may be admitted because he 
has had a severe and serioas attack of haematemesis, and a nurse must be 
prepared to deal with this emergency. She should be familiar with the 
symptoms of severe bleeding, and expect such a patient to be blanched 
in colour, with a subnormal temperature and cold clammy skin, a rapid, 
weak pulse and respirations that are sighing and shallow. In appearance 
the patient will be shrunken, because his body is dehydrated from loss of 
fluid, his eyes will be sunken and his face look pinched; he will be restless 
and anxious unless the degree of shock which accompanies the condition 
is severe enough to render him unconscious. 

The treatment of haematemesis, like the treatment of any other 
case of severe bleeding, is by rest, and this will be obtained by placing 
the patient flat in bed, and reassurir^ him so that he does not worry; 
the physician may order a hypodermic of morphia to be given as this will 
draress the central nervous system and so prevent anxiety, and it will also 
h<dp to arrest bleeding by lowering the blood pressure. 



382 THE ORGANS OP DIGESTION 

Fortunately very few patients die of haematemesis, as the bleeding 
usually stops when the blood pressure is low enough; a few cases continue 
bleeding and in these the progno^ Is very grave. 

The rest which a patient must have if a case of serious haematemesis 
is to be properly cared for by nurses cannot be over-estimated or exag- 
gerated. All the routine musing treatment which is so usual on the 
admission of a new patient must be omitted, as in this case the patient 
must lie totally undisturbed, covered by enough blankets to keep him from 
getting cold. He should not be washed, and no movement of his limbs 
should be permitted. If a sheet is soiled it may not be changed as this 
would necessitate moving the patient. In order to avoid moving him for 
the piupose of inserting a bedpan, should he need one, pads of brown 
wool and tow should be placed on the bed beneath his buttocks, and fresh 
pads can be reinserted as these pads are soiled without disturbing him. 
If a divided mattress is obtainable, it should be employed, as then the 
middle portion can be removed for sanitary purposes and for attending 
to the patient’s back. This patient cannot be moved to have his back 
washed and rubbed, and he most certainly cannot be turned on his side 
until all danger of inunediate bleeding has passed. 

The bed should not be made for at least 24 hours; the top bcdclothing 
might then be rearranged, but the bottom sheet should not be removed — 
it may be untucked and tightened and tucked in again. After 24 hours, 
if the patient’s condition is considered to be improving, his face and 
hands might be sponged; but his arms should not be moved and further 
washing should be pjostponed until he is safely better. 

His mouth will be very dry and he may suffer severely from thirst; for 
the relief of this his mouth should be cleaned frequently and his lips and 
tongue moistened with water, or glycerine and borax and water. It is 
important to try and relieve discomort whenever pcssible. With regard 
to the administration of fluid, the body may not show signs of diminished 
fluid until 24 or 36 hours after the attack of vomiting; but by this time the 
physician will probably have ordered the administration of fluid other 
than by mouth, either in the form of rectal or subcutaneous saline, or in 
more severe cases by intravenous infusion of fluid, either saline or blood. 
Glucose may be added to the saline. As the days pass and the patient 
improves, he will be given fluids by mouth; at first small feedings will be 
given, as indicated in the treatment of peptic ulcer cases on p. 379. 

Professor Meulei^acht of Gopienhagen has introduced an alternative 
method of treatment. He considers the provision of a diet of high calorie 
value and rich in vitamins will produce more rapid healing of a bleeding 
ulcer. In a series of over 200 cases he has given a liberal diet from the first 
day in haematemesis and obtained great success. 

Meulengracht’s diet includes tea and bread and butter, porridge and 
cream, milk and eggs, cream cheeses, cooked finits and ve^tables pro- 
vided these are paa^ through a fine sieve, pounded fish and chicken. 
The day’s dietary may be as follows: 

7 a.m. Tea, bread and butt^. 

9.30 a.m. A little porridge and bread and butter. 

I p.m. (Dinner.) Vegetable soup, pounded chkken and mashed 
potato, green pea pur^e, baked or steamed custard Wltili 



HAEMATBME8I8 3^3 

cooked plums passed through a sieve, rusk or bread and 
cream cheese. 

4 p.m. Tea or cocoa with rusk or biscuit. 

7 p.m. (Supper.) Steamed fish and bread and butter, rusk and 
cream cheese and tea. 


INFLAMMATORY CONDITIONS OF THE ALIMENTARY 

TRACT 

Stomatitis is inflammation of the mucous membranes of the mouth, 
and may be due to a variety of causes, including indigestion, bad teeth, 
pyorrhoea, or the presence of septic foci in other parts of the alimentary 
tract. It occurs in infants when scrupulous cleanliness is not observed in 
the care of feeding utensils; one infantile form which is specific is described 
as ‘thrush’, and is due to a vegetable parasite. 

A similar type of stomatitis is described as catarrhal, while more severe 
types may be ulcerative or gangrenous. Cancrum oris is a severe type. 

TTte treatment of simple stomatitis consists in careful attention to the hygiene 
of the mouth and teeth, and cleanliness of feeding utensils; mild anti- 
septic mouthwashes are employed; the mouth should be cleaned in the 
usual routine manner, with glycerine of borax. Potassium chlorate is 
given. 

Since eating is painful when the mouth is sore, non-irritating fluids 
should be given during this stage, but as improvement takes place the 
patient may be given soft foods and then have soUd food when he is ready 
to take it. 

Cancrum oris is a very serious ulcerative type of stomatitis which is only 
met in debilitated patients, and it requires constant attention to keep the 
parts irrigated and clean; liberal nourishing fluids should be given. The 
aim of treatment is to prevent toxaemia as much as possible and to raise 
the resistance of the patient in order to overcome it. This condition is 
very serious and may prove fatal. 

Pharyngitis has been dealt with in discussion of the respiratory tract. 

TonsiUitis is described in the section dealing with inflammatory con- 
ditions of the ear, nose and throat. 

GASTRITIS 

Gastritis is here considered as an inflammatory condition of the stomach 
such as may be due to infection or irritation by means of infected food, 
highly irritable food, or to some form of poisoning. Dyspepsia has been 
described on p. 378. 

Gastritis may be acute or chronic. The best example of acute gastritis 
is gastric influenza, the symptoms of which are pain in the epigastrium, 
accomp>anied by nausea and vomiting and sometimes by diarrhoea; there 
is a rise of temperature to anything from 101° to 104° F. The mouth and 
tongue axe dry and dirty and the patient complains of severe thirst; all 
the symptoms which usually accompany the febrile state arc present and 
the patient is considerably ]»rostrated by the combination of discomfort, 
toxaemia and loss of fluid firom which he is sufiering. 



384 the organs of digestion 

The treatment adopted is to rest the stomach by omitting all food and 
fluid by mouth, until the nausea and vomiting have ceased and then to 
give fluids, very carefully at first so that vomiting may not be induced, and 
afterwards more liberally, in order to make up for the loss of body fluid. 
The diarrhoea which accompanies the onset of the inflammatory condition 
wiU subside as the patient improves, though the constipation which may 
be present later will require the administration of carefully chosen laxative 
aperients for its relief. 

During the acute attack the symptoms complained of should be relieved, 
and applications of heat may be tried to relieve the abdominal pain, while 
for the headache a small dose of aspirin may be given and the application 
of an ice compress to the head may also help. 

ENTERITIS 

Enteritis is inflammation of the enteron or intestine; either the small or 
large intestine may be affected, and the term colitis is applied to inflam- 
mation of the large intestine, or colon, exclusively. 

Acute enteritis is most commonly due either to bacterial infection or to 
irritation of the intestine by unsuitable foods, infected food or food 
poisoning. 

The symptoms are abdominal pain, which is colicky in nature, 
accompanied by nausea and often by vomiting and by the passage of 
frequent stools which usually contain bile, mucus and undigested food and, 
in very severe inflammatory lesions, blood and mucus in varying quantities. 

Sooner or later, in fairly marked cases as early as 24 hours after the 
onset, the patient will present the typical picture of dehydration, owing 
to loss of body fluid — his face is pinched, eyes sunken, mouth and tongue 
parched and dry, the tongue is furred, and thirst is marked; the pulse in 
rapid, the blood pressure low, and the temperature subnormal except is 
cases due to a very acute bacterial infection when it may be very high. 

The treatment aims at the relief of the dehydration and of the other 
symptoms which are present; hot applications are applied to the abdomen 
in an attempt to relieve the pain; in many instances the physician will 
order morplua; the patient is kept in bed as warmly clad as possible and, 
as he rolls about in pain, it is necessary for a nurse to stand at the bed- 
side constandy covering him with the bedclothes. 

The administration of fluid is important, and yet this may be impossible by 
mouth or by rectum in cases where vomiting and diarrhoea are marked 
symptoms, and sedative drugs will be used to allay the restlessness which 
is due to pain, starch and opium enemata being employed to lessen the 
number of stools. If the patient is very prostrated it may be nccessary_^to 
give saline by the intravenous route. 

As soon as the attack begins to abate water can be given by mouth, 
then albumin water, glucose and whey, giving as much as the patient can 
take and keeping him on similar fluids until the inflammatory condition 
can],be considered to be improving; he may then be given diluted^’^milk 
and gradually allowed mifley foods and light diet when aU symptoms^have 
di^peared. 

Ine mouth should be carefully and frequently cleaned throughout the 
illness, and kept as moist as posdble as thu will help to allay thirst. 



ENTERITIS 385 

In cases where diarrhoea and vomiting are present the ttse of aperients is contrain- 
dicated; the stomach and intestine are ^rcaidy irritated and the adminis- 
tration of an aperient will only increase the irritation. There is such a 
tendency to administer castor oil to patients with gastro-intestinal dis- 
order that this cannot be too emphatically stated. The only occasion when 
castor oil or any other aperient may reasonably be employed is when an 
attack of enteritis is known to be due to the taking of some unsuitable 
food, as when a tiny child eats too many green apples; but even in this 
case the child will suffer pain, and should therefore be put to bed and 
kept warm until the aperient has acted, and during this time his stomach 
should be kept at rest — later, when he is better, he may be given diluted 
milk and water. 

Chronic enteritis may occur. This type is often tuberculous in origin, and 
is associated with intermittent attacks of pain, malaise, loss of weight and 
a varying degree of pyrexia. 

COLITIS 

Ulcerative colitis is an acute inflammatory catarrhal condition of the 
large intestine, due to bacterial infection or occurring as the result of a 
severe toxaemia. 

It is characterized by a rise in temperature, marked wasting, dbtension 
of the abdomen and the passage of frequent watery, offensive stools, con- 
taining blood and mucus. This disease may last for many weeks, the 
patient becoming more and more prostrated and the toxaemia more 
marked. 

The treatment adopted is complete rest in bed; these patients require 
very careful nursing as they are often emaciated and therefore liable to 
bedsores; the frequent passage of stool necessitates constant attention and, 
as the prostration becomes very marked, it will be found that the patient 
passes fluid stool involuntarily. The medical treatment consists in the adminis- 
tration of non-rcsiduc bland diet (sec p. 288); in some cases local treat- 
ment in the form of colonic lavage is undertaken (the method of adminis- 
tering this is described on p. 136). 

Another form of colitis is described as muco-znembranous colitis or 
mucous colitis. It occurs in persons who have led a worried life and 
possibly have a tendency to neurasthenia, and is characterized by consti- 
pation, though in some cases this alternates ivith attacks of diarrhoea. 
The stools frequently contain large shreds of membrane or even casts of 
the colon — hence the name, muco-membranous colitis. 

The alimentary tract of these patients is disordered and they suffer from 
loss of appetite, nausea and indigestion. 

’Tht treatment is the administration of a bland diet. The bowels are kept 
acting by the careful use of bland laxatives such as liquid paraffin or senna 
tea. Strong or irritating aperients must be avoided. Colonic lavage is 
employed. An important part of the treatment may be to discover the 
cause of any underlying neurasthenia such as the existence of a septic 
focus and then to try to treat this. 

DIVERTICULITIS 

Diverticulitis is inflammation of little sacs which lie in the walls of the 
colon, particularly at the lower end, and when these become infected 



386 THE ORGANS OF DIGESTION 

or irritated the resulting infisunmatory changes in the colcm are quickly 
transmitted to the peritoneum when the infection is an acute one, and this 
gives rise to symptoms similar to those of appendicitis. The treatment the 
acute type of dioerticuliiis is surgical. 

Chrome diverticulitis may a^ occur, characterized by constipation and 
by the passage of mucus, accompanied by colicky pain. Medical treatment 
employed consists in the use of a bland diet, the amninistration of laxative 
and lubricating aperients, and colonic lavage. 

EPIDEMIC DIARRHOEA 

Epidemic diarrhoea or, as it is commonly termed, summer diarrhoea, 
is an acute infective inflammatory catarrhal condition of the intestine due 
to several organisms. It affects infants and young children and is most 
commonly met with during the hot months of the year when flies and dust 
are present in great quantities and when infection of food, particularly 
milk, is therefore most likely to occur. 

The symptoms are similar to those described in a case of ulcerative 
enteritis. At first vomiting and diarrhoea are marked. An infant admitted 
in this condition will be very seriously ill. The temperature may be high, 
the pulse rapid, weak, running, thready and compressible; dehydration 
is present, and will be indicate by sunken eyes, boat-shaped abdomen, 
sunken fontanelle and inelastic skin; thirst, prostration, toxaemia and col- 
lapse are marked. Unless relief can be obtained the infant will die. 

The treatment adopted is absolute rest, applications of warmth, and 
the administration of fluid, either by the peritoneal or intravenous route. 
When danger of death is more remote, the stomach may be gently washed 
out and the bowel irrigated; then, when these organs have had a little 
rest, some non-irritating fluid may be given — small sips of water at first 
by mouth, then whey, albumin water, glucose and water, and — ^by 
rectum — saline with glucose. 

In the nursing care of this tiny infant great gentleness is necessary; and he 
should be kept warm, and it is a good plan to nurse him on a water 
cushion, containing water at 120® F., and to wrap him in cotton wool, or 
light warm woollies. The fluid given by mouth must be administered very 
slowly and at frequent regular intervals. His mouth should be kept moist 
by applications of boroglyceride. 

Isolation is very important, as this disease is highly infectious and the 
excretions and vomited matter are potent sources of imection. The nurse’s 
hands must be carefully washed after handling infected articles, especially 
napkins. In some hospitals certain nurses are responsible for the babies’ 
feedings; others deal with the washing of the babies and the care of the 
cleanliness of their buttocks and napkins, and thus any possibility of infect- 
ing the feeding utensils is prevented. 

DIARRHOEA AND CONSTIPATION 

Diarrhoea is the term used to describe the condition present when an 
excessive number of stools are passed; 4 m* 5 stools a day would constitute 
a state of dianiioea, whilst 8 or 10 wotdd be conridered very excessive. 



DIARRBOBA AND CONSTIPATION 387 

The Houses ^ diarrhoea are very numerous, and in addition to epidemic 
diarrhoea, which has been described above, where inflammatory con- 
ditions of the alimentary tract are dealt with, diarrhoea is present in some 
cases of typhoid fever, and in cholera and dysentery and in most inflam- 
matory conditions of the intestine (see also enteritis). 

In infants it may also be due to unsuitable feeding, or either over or 
underfeeding. In adults the number of causes include dietetic errors, par- 
taking c€ decomposed food, and food poisoning; it occurs as a symptom in 
mercurial poisoning, and may also occur under conditions of emotional 
stress. 

The treatment of diarrhoea is to investigate the cause and then to direct 
treatment towards its removal; in the meantime, as the patient is losing a 
good deal of fluid, he should be kept at rest, preferably in bed, and sho^d 
be kept warm and comfortable. Any pain which accompanies the passing 
of stool should be relieved by apphcations of heat to the abdomen; the 
patient’s mouth should be kept clean and his lips and tongue as moist as 
possible; if he is not vomiting, he may be given water, or half-strength 
saline containing glucose to sip; his drinks should be warm, neither hot 
nor cold, as extremes of temperature may stimulate peristalsis and result 
in his passing a stool immediately after taking a drink. It is impx>rtant to 
note whether this happens as, if it does, it may indicate that there is irrita- 
tion of the gastro-colic reflex, causing the ileo-caecal valve to open and 
allow some of the contents of the small intestine to pass through and so 
set up peristalsis in the large intestine each time fluid enters the stomach; 
in such a case the administration of fluids would have to be arranged at 
regular intervals only, cither every 3 or every 4 hours. 

Patients who are having frequent stools soon become very tired; they 
get thin and the pressure of a bedpan on the skin of the lower part of the 
back predisposes to soreness — some means should therefore be taken to 
pad the pan and made it soft. The patient should be washed and powdered 
locally liter the use of the pan and observation made to see whether the 
stools are making the skin sore; if so, it should be protected by an applica- 
tion of some slightly greasy preparation — carron oil, which is a mixture 
of linseed oil and lime water, is excellent for this purpose, and the skin 
might be cleansed with this instead of with soap and water when the 
stools are very frequent and the skin tender and reddened. 

The generaJ appearance of the stools must be carefully observed. 

Constipation. In this condition the output from the bowel is di- 
minished. Normally, the amount of faeces passed by an adult is 4 oimces 
once a day. In constipation the action may be rare, occurring only once 
in several days, or, occurring daily, it may be small in quantity. 

The causes are numerous. The diet may. indude insufiident fat, or it may 
not contain enough fresh fruit and vegetables and water, or it may be too 
rich in meat. Sometimes a patient omits the use of valuable fats and cereals 
because he is afraid of 'putting on weight’. 

Any neglect of the r^[ular emptyii^ of the bowel will result in failure 
of dre re^ex to act and in time this will lead to constipation. If the impulse 
to defaecate is ignored on one day, it may not occur until the same time 
next day and, if ignored again, intgularity may be set up. The training 
d* children to have their Mwels opened at the same time each day is 
very great importance in the formation o£ a good bowel halnt. 



388 THE ORGANS OF DIGESTION 

The taking of aperients or the administraticHi of enemata regularly is 
another cause of constipation since, as the result of these, the bowel may 
not function without the artificial stimulation provided. 

Other causes include atony of the bowel wall; weakness of the abdominal 
muscles; spasticity of the muscle of the waJl of the bowel which gives rise 
to tight contracted bands, damming back the contents; any form of indi- 
gestion which is caused by decrease in the normal digestive fluids may 
cause constipation. The presence of any obstruction such as might be 
caused by the existence of a tumour in the pelvis or lower part of the 
abdominal cavity; or by a strangulated hernia, or intestinal obstruction 
will result in constipation. When the obstruction is complete there is con- 
stipation of flatus also. 

The treatment of constipation, apart from the removal of any definite 
cause such as indigestion, aims at providing the type of diet which will 
be effective in prc^ucing a normal action of the bowel each day. This 
dietetic treatment is described in detail in the section dealing with diet 
on p. 287. 

WORMS 

Intestinal worms. The worms which most commonly live in the 
human intestine are threadworm, roundworm and tapeworm. 

The threadworm or oxyuris vermicularis is small, being less than half an 
inch in length; it lives in the caecum and migrates to the lower end of the 
colon at night, where it causes intolerable itchii^ about the anus; it is 
visible as a tiny piece of cotton thread. 

The round worm or ascaris Ittmbricoides is several inches long, lives in the 
upper part of the small intestine and causes considerable abdominal dis- 
comfoit, pain and diarrhoea. 

The tapeworm most commonly found in the intestine of man is the type 
described as taenia mediocanellaia, which is conveyed by eating encysted 
beef, and the taenia solium by eating encysted pork. These worms are both 
from 10 to 40 feet long, segmented, with a tiny head by which they burrow 
into the intestine and attach themselves to the wall thereof. As ^e result 
of infection by tapeworm the patient suffers malaise and discomfort, loses 
weight and becomes anaemic. 

Treatment. These wmms are parasites, living, that is to say, on and at the 
expense of their host — ^in this case, man. The principle of treatment is to 
rid the body of the worms by using some drug which will stupefy them and 
then to remove their surrounding medium by pui^atives and so render 
them imcomfortable; further purgation will usually result in the expulsion 
of the worms. The substances which will help to get rid of worms arc 
described as antkdmintics. 

In the treatment of tapeworm, extract of male fern or filix mas is used, but the 
patient requires to lx specially prepared fenr this, and the treatment is 
carried out as follows — ^The patient is admitted and, as the treatment 
is apt to be very severe, he is kept in bed. His diet conrista of weak tea and 
beef tea only; on the second day the administration of purgatives is begun, 
the patient being given 2 drachms o£ mamesium nilphate three tixna a 
day; this is repeat^ on the third day and on the morning of the fourth 
day one dose is given in the early momii^;. Two hours later tlx extract 
of male fern is administered. It is a fluid extract, 15 minims are given, and 
rqxated every quarter of an hour until 1 or drachms have been ad- 



WORMS 389 

ministered. Two hours afterwards the patient is given another purgative 
usiudly in the form of i ounce of blade draught which contains magnesium 
sulphate, liquorice and senna. 

Afta: this treatment the patient may be expected to pass tapeworm 
and the stools must be very carefully inspected; at first considerable 
quantities of segments will be passed; the smaller segments are nearest the 
head end of the worm; it is important to search diligently for the head, and 
it can be recognized as a tiny triangle, almost as small as the head of an 
ordinary pin. 

In order to be able to inspect the worm easily, it is advisable to put a 
little tepid or warm water in the bedpan, as this prevents the separation 
of the segments and so makes it easier to see the head of the worm should 
it be passed. The stools should all be passed through a fine hair sieve, black 
crape having formerly been used for this purpose — in either case the 
material is Sne enough to prevent the head of the worm from passing 
through it. 

If this treatment is not effective and the head of the worm is not re- 
covered, the patient will have to return home and wait for three months 
before it can be undertaken again. 

Another drug which is used in the treatment of tapeworm is pellctierine 
tannate; preliminary starvation and purgation is employed as before, one 
dose of the drug, from a to 8 grains, is given, and the final purgative 
administered 2 hours after this. 

Santonin is used in the treatment of roundworm and in some cases of thread- 
worm, when the condition is persistent. The patient is given very light 
diet for a day or two, a dose of castor oil is given on the last evening and 
the dose of santonin, from i to 5 grains, is given next morning whilst the 
stomach is empty and before any food or drink is taken. If the bowels are 
not thoroughly opened, a dose of magnesium sulphate is given later in the 
day. The stools are then inspected for the worms which will usually be 
passed. 

In the treatmerU of threadworm attempts are made to get rid of the worms 
by local measures; the colon is irrigated either with an infusion of quassia, 
a I per cent, solution, or by a hypertonic solution of saline. 

In addition to getting rid of the worms it is important to apply germi- 
cidal ointment, such as a preparation of mercury, in order to destroy any 
that migrate to the anus during the night; soothing preparations are 
employed to relieve the intense irritation and means are taken to prevent 
the patient, who is usually a child, from reinfecting himself by putting his 
hands to his mouth after handling the area of his anus as he may do by 
scratching to obtain relief from itching. 

PYLORIC STENOSIS. HIRSCHSPRUNG'S DISEASE. 

VISCEROPTOSIS 

Congenital hypertrophic pyloric stenosis is a rare condition which 
occurs in tiny infants, and it is very important that a nurse in a general 
hospital should know how to deal with this infant, as such cases may be 
admitted cither for medical or surgical treatment. 

It is thought that the condition is probably present at birth, but it docs 
not usually produce any symptoms until the baby is several weeks old. The 
fibres of tnc pyloric end of the stomach then become tightly contracted. 



390 THE ORGANS OR DIGESTION 

The symptoms are— ’Vomiting which becomes ftarcibly projectile in char- 
acter, meaning that it is projected on to the floor beyond the cot; the baby 
is ravenously hungry and sucks his fist continuously; he whines and cries, 
his urine becomes scanty and he prnents the appearance of a baby who 
is extremely dehydrated. On examination of the abdom^ peristalsis may 
be visible as a ball, about the size of a golf ball, passing from left to right, 
The contracted pylorus can sometimes be felt. 

Mtdical treatmaU consists of gastric lavage, with saline solution, once or 
twice a day, or every 4 hours. Feedings should be given in small quantities 
at regular intervals, expressed mother’s milk being used. The nurse should 
use her ingenuity to try and get some milk retain^ in the stomach; giving 
a second feeding imm^iately after one the baby has vomited may succeed 
and thickening the milk sometimes helps. Small doses of atropine may be 
ordered to relax the pyloric sphincter and small doses of mildly sedative 
drugs, such as bromide, may be useful to assist relaxation and diminish 
the neuromuscular irritation which may be producing the condition. 

Surgical treatment is by means of Rammstedt’s operation, the fibres of the 
sphincter being partially divided. 

Preparation q/" an infant for the perfomumce of Rammstedt’s operation when a 
local anaesthetic is used. Sixty cubic centimetres of normal saline are adminis- 
tered by the intraperitoneal route four hours before the operation is to 
be performed, and the infant is given a warm bath two hours later. The 
stomach is washed out with normal saline i ^ hours beforehand and then 
the infant is bandaged on to the fixation splint, as shown in the illustration, 
and kept very quiet for at least an hour before being taken to the operat- 
ing theatre. 

A finding of glucose and water ready prepared in an infant feeding 
bottle, but with a piece of sterilized linen inserted in place of the ordinary 
rubber teat, is taken to the theatre. The infant is allowed to suck this 
during the operation; it helps to keep him quiet; he may vomit what he 
has t^en on return to the ward, but does not usually vomit during the 
short time he is in the theatre. 



A Looai. ANAzmoma 



PYLORIO STENOSIS 39I 

Hie cot is prepared for the reception of the infant immediately after the 
op^ation, the foot of it being dilated on low blocks; a water pillow is 
jBlled with water at a temperature of 1 18® F. and placed in the bed, covered 
by a blanket; an electric cradle is placed on the bed, under the upper 
b^clothes and the electricity is turned on. 

The post-«peratioe treatment commences immediately — ^when performed 
under a local anaesthetic the operation takes less than five minutes. Hie 
infant is lying on the fixation splint, wrapped up in cotton wool, a surgical 
dressing is placed on the operation wound, covered by a pad of wool, and 
this is retained in position by a many-tailed binder. The infant is placed 
in his cot, and the electric cradle is generally removed as the bed is ready 
warmed and the infant does not usually suffer from shock. The danger to 
be feared is hyperthermia; the pulse and temperature are taken every 
hour for the first 12 hours; after two hours the infant’s temperature may 
be expected to be 100® F. When the temperature has reached this point 
the bandages and wool may be removed and the use of the fixation 
splint omitted; the dressing on the wound is now secured by an abdominal 
binder made to fit the infant and his clothing may be put on. If the 
temperature continues to rise, when it reaches 102.5° icebag may be 
applied to the head; if this fails to relieve the condition of pyrexia the bed- 
clothes covering the infant may be removed, and if the temperature still 
continues to rise his body may be sponged with tepid water. 

Post-operative feeding commences 4 hours after the operation; expressed 
breast milk should be given. For the first 20 hours, small quantities are 
given — from the ist to the 3rd hour, i drachm is given each hour; at the 
4th and 5th hour, 2 drachms each hour; fi'om the 6th to the gth hour, 
3 drachms each hour; at the loth and i ith hour, 4 drachms each hour; 
from the twelfth hour, 6 drachms may be given every 2 hours; and from 
the 16th to the 20th hour, i ounce every 2 hours. 

The end of the first 24 hours has now been reached, and during the 
second 24 hours the infant is given 1 1 ounces every 2 hours for the first 
12, and 2 ounces for the second 12 hours. The return to normal feeding is 
now gp-adually made until, by the 5th day, the normal routine should be 
established. 

Pyloric stenosis sometimes occurs in adults, but it is then most often 
due to the formation of adhesions, scarring and contraction which may 
complicate a pqitic ulcer. 

Hirschsprung’s disease or megalocolon is a hypertrophic condition 
of the colon vHbich is probably congenital although it may not be noticed 
for a ninnbcr of years. It is due to functional derangement of the nervous 
control of the colon, and is characterized by marked dilatation and dis- 
tension; the treatment adopted is sympathetic ganglioncictomy, meaning that 
certain nctve ganglia are removed in order to cut off the passage of nerve 
impulses to the part affected, in an endeavour to relieve spasm and 
permit the dilated colon to return to its normal size. 

Viscsroptosls is a dipping of the viscera — most often of the hollow 
organs such as die stcanach and large and small intestine — but the solid 
''rgans can be Sapheed also, the d^lacement of the kidney giving rise 
to the oooditioQ described asfio<Uing kidn^ is an example. 

When the stomach or intestines have dropped lower down in the 
abdominal cavity than they should normally he, the symptoms of the 



392 THE ORGANS OF DIGESTION 

condition are dyspeptic in character. The patient is easily tired, he is 
languid and incapable of exertion; in many cases he is thin and wasted 
and feels the cold severely. In some cases of gastroptosis acute attacks of 
vomiting occiu' at intervals. 

Treatment is directed to improvement of the general condition of the 
patient; his weight should be increased, he needs rest and should be 
advised never to overtire himself, particularly he should rest before and 
after his meals; he should try and discover the foods which agree with 
him and have regulai'ly spaced meals, and his bowels should be kept open 
by laxative. 

DISEASES OF THE LIVER AND GALLBLADDER 

Jaundice is a term used to describe a condition in which the skin is 
tinted and the conjunctiva discoloured yellow, due to retention of the bile 
pigments in the blood, and is usually brought about by congestion, or 
obstiiiction, of the bile capillaries and ducts. This condition exists in 
catarrhal and obstructive jaundice. In the former, an inflammation which 
may be of an infective character causes congestion of the lining of the 
biliary tract and results in an acute attack of jaundice, lasting about 3 
weeks, which in addition to the symptoms of jaundice detailed below is 
characterized by a rise in temperature. In obstructive jaundice the bile is 
dammed back and, as it cannot escape into the duodenum, it gets into 
the blood, and this may be due to the presence of gallstones in the duct 
or to obstruction due to pressure upon the duct, such as would happen in 
the case of a tumour at the head of the pancreas. 

Jaundice is a condition due to the retention of the bile pigments in 
the blood, and this ufiay also happen in certain diseases, and in some com 
ditions of poisoning, when the red blood cells are disintegrated in the 
blood stream, without the intervention of the liver and spleen. This state 
occurs in haemolytic jaundice or acholuric jaundice which is due to a disease 
of the spleen. It may also occur by the introduction of p)oisons, particularly 
when these have a destructive action on the tissue of the liver. Examples 
of such poisons are snakebite and tetrachlorethane, the latter being used 
for painting the wings of aeroplanes and the subject poisoned by inhaling 
the fumes from this. Trinitrotoluene (TNT), used in munition factories, 
is another similarly poisonous substance. 

Haemolytic jaundice may also be met with in patients who are intolerant 
to the organic compounds of arsenic employed in the treatment of syphilis. 
It is for this reason that, in the preparation of patients for these injections, 
the precaution is taken of administering glucose in order to fill up the 
fiver cells and so protect them from the effects of this poisonous substance. 

Infective catarrhal jaundice is due to a filter-passing virus. The incubation 
period is long — twenty-six to thirty-five da>'8. The onset is characterized by 
lassitude, headache and nausea. Vomiting and abdominal pain follow and 
jaundice appears. 

Weil's disease, which is due to the heptospira ictero haemorrhagiae, is spread 
by rats. The incubation period is seven to fourteen days or lon^. The onset 
is abrupt with prostration and high fever; jaundice appears by the fourth 
day of disease. After the tenth day the fever declines by lysis. Remissions 
are common. Cases of either of these types of jaundice &ould be isolated. 
Treatment consists in relief of the sym^ms which are enumerated above 
and a diet as described below. 



DISEASES OF THE LIVER AND GALLBLADDER 393 

The symptoms of jaimdice. Tinting of the ddn and conjunctiva, 
which may vary from pale to bright yellow or even, in severe cases, to 
olive green, is the most characteristic symptom. The skin is irritable owing 
to the retention of bile salts. 

The urine and other secretions, except the stools (see note below), are 
coloured by the bile. The urine varies from a slight greenish-yellow tint 
to deep mahogany colour. When shaken up the froth looks multicoloured 
in bright daylight. 

The stools are pale and are described as putty or clay colour; the faeces 
are dry and crumbling in consistence and offensive in odour, and they 
may contain undigested fat. 

Owing to the absence of bile the functions of the digestive tract arc 
disorganized, there is loss of appetite and nausea, particularly at the sight 
or even sometimes the thought of fat, and vomiting may occur .';^Constipa- 
tion is usually present. 

The patient is lethargic and often depressed, and this is due to the 
action of the bile salts on the central nervous system. He feels the cold 
easily and yet, when he gets warm, his skin often begins to itch intolerably; 
thus he is faced with being alternately cold and itchy — both very uncom- 
fortable states — and consequently he finds it difficult to sleep. The tem- 
jjcrature, except in infective catarrhal jaundice, is usually subnormal, and 
the pulse is slow, as the bile products depress the circulation. 

Treatment and Nursing. In the routine care of a case of severe jaun- 
dice a nurse will find her resources severely taxed; she has to deal with a 
depressed difficult patient, one who is constantly irritated by the itching 
of his skin and in many cases one in whom the sight of food causes uncon- 
trollable nausea — patients sometimes cannot bear to see or consider drink- 
ing even skimmed milk. In her care of this patient the nurse will bear 
constantly in mind the distressing symptoms from which he suffers, as the 
medical treatment employed for the relief of these vrill be largely in her 
hands, and will require constantly applied intelligent thought and con- 
sideration. 

The diet will be as free from fat as possible and, during the stage when 
nausea is acute, bland fluids containing glucose may be all that the 
patient can take; he may, however, be persuaded to try fresh fruit, 
appetizingly prepared, and fresh green salads; these may be dressed with 
a httlc blade pepper and vinegar, oil and salad creams being omitted. A 
patient may be induced to take some toasted breadcrumbs, a little of the 
specially prepared breakfast toasties or a small piece of dry toast with his 
sadad. As he feels a little better, he may be willing to take cooked fruit and, 
as sugar can be added to this, it becomes a v^uable source of food for 
him. During serious nausea and vomiting, water, or alkaline drinks, 
should be given as freely as the patient can be persuaded to take them. 

As the condition improves the diet may be increased, but it is important 
for some time to eliminate fats and eggs, as the latter contain fat and 
cholesterol. Fluid may be. given in abundance, and the patient should be 
encouraged to drink plenty of water, lemonade and grapefruit drink or 
any other fruit drink he fancies. 

It is important to inspect the stools for any undigested food, especially 
fat. The bowels should be kept acting regularly, and it may be necessary 
to use aperients. 



394 OROAN8 or digestion 

Saline aperients >vill be found nusst acceptable; sixne physicians order mer- 
cury in ^e form of calomel, but nausea would be considered contrain- 
dicative to the use of calomel and a saline aperient would then be sub- 
stituted. 

Other drugs which may be wtkrtd include hexamine and salol, both of these 
acting as biliary antiseptics. Various alkalis and bismuth may be employed 
for tlM rdief of vomiting but bismuth causes constipation. Sometimes, when 
the irritation of the skin is very marked and is causing undue distress to 
die patient, a physician may order a diaphoretic; pilocarpine is an example 
t^this, the dose being from i/8th to i/ 4 th of a grain administered by hy^- 
dermic injection. It is a powerful diaphoretic and the skin will act fredy, 
thus bringing some of the irritating bile salts away in the perspiration. 
Hot sponging should follow in order to get the best result, by removing 
the products perspiration. 

Other means of relieving the irritation of the skin arc by sponging with 
weak carbolic, a solution of i /too, or a solution of sodium bicarbonate, or 
borax, or calamine lotion may be dabbed on. 

Jaundice is occasionally, but not invariably, associated with gallstones, 
and when due to this cause attacks of biliary colic may ensue; it is neces- 
sary to be on the watch for pain over the region of the gallbladder be- 
cause, apart from the presence of stone, viscid thick bile may act as an 
obstruction. 

Attacks of biliary colic necessitate the use of heat and counter-irritants in 
an attempt to rdievc the pain; but morphia will usually be ordered for 
this, as the p>ain is severe and very prostrating in its effects (see also colic 
on p, 344). 


CHOLECYSTITIS 

Cholecystitis is inflammation of the gallbladder, and it may be cither 
acute or chronic. Acute cholecystitis gives rise to symptoms of an acute 
abdcnninal condition, very like those of appendicitis, only that in this case 
the inflammation affects the upper, rather than the lower portion of the 
abdominal cavity. It is thought in many instances to be due to infection 
by bacillus coli. 

The symptoms are abdominal pain, nausea and vomiting accom- 
panied by a rise in temperature; the abdomen is tender, particularly over 
the right upper quadrant; pain passes round the epigastrium and up to 
the right shoulder. 

Medical treatment, if it should be decided to adopt this, consists in the 
administration of morphia to relieve the pain and counter-irritants and 
hot applications applied over the region of the gallbladder; the patient is 
kept m bed and plenty of water is given when vomiting ceases and he can 
retain it. When the attack of acute pain has subsided, biliary antiseptics 
are ordered to dilute the bile, and a small dose of concentrated mamiesium 
sulphate is given each morning in an endeavour to drain the gallbladder. 

The diet consists of mild, non-fatty foods and plenty of fluid containing 
glucose, fresh fruit and green vegetables. 

Gliroiiic dbolecystitis usually occurs about middle age, and it may 
follow acute attacks or begin more insidiouriy with recurrent attacks of 
indigestion. 



okoLiscvsTitis 395 

The usual history of a patient with chronic cholecystitis is of this nature — 
indigestion, characterized by a sense of fullness after meals, which is more 
marked towards the end of the day and particularly after partaking of tea, 
pastry, foods cooked ki fat, sardines, herring and salmon; the patient is 
often fat and heavy, and suffers from constipation; he has attacib of pain 
on the right side and suffers from frequent headaches; he mayjiave acute 
attacks of pain due to biliary colic and he may, though this is rare, say 
that he has sometimes been jaundiced. 

Treatment is on the lines indicated in acute cholecystitis. Cholecystography 
is usually undertaken in order to investigate the function of the gall- 
bladder. This test has been described in the section dealing with investi- 
gations on page 2 1 1 . In persistent cases, and because an inflamed gall- 
bladder is always Liable to be the cause of an acute abdominal catastrophe, 
surgical measures are commonly undertaken. The care of a patient on whom 
cholecystectomy has been performed is described on p. 672. 

CIRRHOSIS OF LIVER. LIVER ABSCESS. ACUTE YELLOW 

ATROPHY 

Diseases of the liver more rarely seen are cirrhosis, liver abscess and 
acute yellow atrophy. The liver is one of the sites of hydatid cyst, a condition 
due to infection by means of the tapeworm of the dog; in this type man 
becomes the intermediate host and the parasite develops in his tissues, a 
hydatid cyst sometimes growing to a very large size. The treatment is 
removal of the cyst. 

The liver is also a common site for metastatic growth in cancer — 
secondary carcinomatous lesions. This is easily understood when it is remem- 
bered that the liver receives the portal blood; secondary growths in the 
liver may lead to marked interference with its function, resulting in jaund- 
ice as the result of obstruction, and also in ascites. 

Cirrhosis of the liver is a type of degeneration which is due to 
toxaemia and is known to be frequently associated with taking excessive 
alcohol, though this is not an invariable cause of the condition. 

The symptoms are those which result from obstruction of the portal 
circulation, such as chronic indigestion; attacks of haematemesis occur, 
melacna is present in the stools and, as time passes, the patient becomes 
wasted, anaemic, jaundiced, ascites occurs, and the prognosis is con- 
sidered to be serious. 

Treatment is palliative; the limitation of spirits is important and the diet 
should be light and easily digested. Rest is essential. 

Liver abscess is usually associated with amoebic dy^sentery, and it is 
characterized by pain and tenderness over the liver with rigors, a rise of 
temperature and marked prostration. 

Acute yellow atrophy of the liver is a very rare condition which is 
thought to be due to severe forms of toxaemia. The patient becomes 
seriously prostrated. 

TESTS OF HEPATIC FUNCTION 

The Van den Bergh reaction is employed in cases of jaundice and suspected 
jaundice as by means td’ it the character of the bile in the blood is in- 



396 the organs of digestion 

vestigatcd, and from this the type of jaundice present, whether obstructive 
or non-obstructive, is determined. 

Graham's Test (cholecystography) used to test the function of the gall- 
bladder is described on p. 211. 

Lyon’s Method of collecting specimens of bile is used to investigate the 
contents of the duodenum and determine the character of the bile passing 
into it (see p. 212). 



Chapter 25 

Diseases and Disorders of the Organs of 
the Urinary Tract 

Nephritis^ acute and chronic — Uraemia — Infections of the urinary tracts pyelitis and 
cystitis — Disorders of micturition 

NEPHRITIS 

N ephritis, which is also known as Bright’s disease, is inflammation of 
the kidneys, and it may be cither acute or chronic. Acute nephritis 
affects the entire organ; of the two forms of chronic nephritis 
usually described, one — chronic interstitial nephritis — affects the interstitial 
tissue between the tubules, and the other type, chronic parenchymatous 
nephritis^ which is also described as chronic tubular nephritis, affects the tubules. 
Another form results in a degeneration of the substance of the kidney and 
is known as nephrosis, in order to distinguish it from nephritis — kidney 
inflammation. 

There are many causes of nephritis, but the acute form is most com- 
monly due to bacterial infection and may be associated with infectious 
fevers, such as scarlet fever, or with influenza; it is also caused by toxic 
bodily conditions, so that a badly infected focus anywhere in the body 
may cause nephritis; it occurs as a complication of pregnancy when 
toxaemia is present; it is sometimes due to very intense irritation of the 
kidney, as may occur when certain irritant poisons — such as carbolic acid 
or turpentine — have been taken and the kidney, trying to eliminate the 
poison from the body, becomes inflamed and a state of acute nephritis 
results. 

Of the two examples of chronic nephritis given above, chronic tubular 
nephritis may follow the acute type, or the condition may have been 
chronic from the outset; in this case the onset is insidious rather than 
rapid. Chronic interstitial nephritis is often caused by slow poisoning of the 
system by toxins or poisons, as by chronic constipation, gout, rheumatism, 
syphilis, chronic alcoholism and chronic lead or arsenical poisoning. It is 
£dso very closely associated with arteriosclerosis and with a raised blood 
pressure. 

The nursing of nephritis is very interesting. It is necessary to know the 
symptoms of this disease, but it is even more necesssary to remember the 
important functions of the kidneys — ^man cannot live without a reasonable 
amount of healthy kidney tissue — ^and when the functions of the kidneys' 
arc understood by a nurse she can do much by her general care of a 
patient with nephritis to relieve the work of the kidneys by stimulating the 
skin to free action and so help to rid the body of urea and other nitro- 
genous waste products. Stimulation of the large colon to eliminate water, 
by giving aperients which will result in watery stools, combined with a 
limitation of the intake of food which would leave waste to be got rid of by 
die ki^cys and, within reason, a restriction of the intake of water, are the 
principles which umierlic the nursing cases of nephritis. It requires 

m 



398 THE ORGANS OF THE URINARY TRACT 

intelligence to apply these principles, but for that very reason the work can 
be profoundly interesting, and often very satisfactory. 

ACUTE NEPHRITIS 

Acute nephritis is usually characterized by a fairly rapid onset, in 
which the temperature rises, the pulse quickens, the skin becomes hot 
and flushed, there is furring of the tongue, loss of appetite, nausea and 
vomiting, headache, marked malaise and in some cases sore throat is 
present. 

The urine is very characteristic, it is small in quantity, and contains albumin 
and blood; the urinary output may be seriously diminished, and the 
patient who passes only several ounces a day is threatened with complete 
suppression. 

Complete suppression of urine is also termed anuria, as mine is entirely 
absent and the function of the kidneys in abeyance; this condition cannot 
last long, it will prove rapidly fatal as the urinary waste products are in 
this case being stored up in the blood and will lead to uraemia. Partial 
suppression, in which the quantity of urine may be seriously diminished, 
even to 6 or 8 ounces during 24 hours, is a condition through which good 
nursing may carry a patient safely, even over many days, provided his 
resistance and strength can be maintained. 

A patient with acute nephritis is seriously ill and is threatened with 
uraemia; his skin is dry and it is difficult to make it act freely, though this 
is necessary; his mouth is very dirty, and his breath is often offensive; 
continued nausea and headache render him very uncomfortable; oedexna 
may or may not occur, but when it does happen it usually begins in the 
loose subcutaneous tissues about the eyes and of the scrotum; later, it 
occius in dependent parts as the ankles and over the sacral region and if it 
spreads ascites occurs. 

Acute nephritis remains an acute illness for about 3 weeks; in a satis- 
factory case the symptoms begin to abate about this time, the urine be- 
comes clearer, containing less blood, then very little blood, and fin^y 
the amount of albumin begins to abate; more urine is passed and in about 
5 or 6 weeks from the commencement of the illness the urine may be quite 
clear. 

Treatment and Nursing. The principles of nursin'g have been men- 
tioned; a patient with nephritis requires a blanket bed, he should wear 
light warm woollen clothes and have some form of artificial heat in the bed 
— all this in an attempt to make the skin act. For the same reason the akin 
should be washed or sponged with really hot water (from 1 tS® to 120“ F.) 
twice a day; this heljM to remove waste products, the treatment should be 
carried out faiily rapidly and briskly, taking care to see that chilling of the 
patient does not occur. After he has been washed, the patient should be 
cosily tucked up, all his wants being attended to at the same time; if he ia 
given a hot dnnk, covered up and allowed to lie, resting, there will be 
some hope that his skin will act, and in this way excretion of water will be 
obtained and the function of the kidney assisted. 

As a patient with acute nephritis is very ill, and suffering from marked 
malaise, the usual nursing attentions necessary for the preveatitm of bed- 
sores must be carried out; special care will be needed if oedooui occurs, as 



ACUTE NEPHRITIS 399 

then the skin is stretched and so deprived of its normal supply of blood, 
and bedsores may easily occur. 

The dut will be carefully ordered by the physician; as very little urine 
is being passed and much blood and albumin are being lost, showing that 
the kidney is highly inflamed and incapable of functioning, he may go so 
far as to eliminate all protein, even diluted milk, for the first 7-10 days of 
illness, giving only 1^2 pints of lemonade and from 6 to 8 oimces of 
glucose in order to supply the patient with some nourishment during this 
time. In this" case the physician will begin to order a little milk at the end 
of 10 days, taking care not to give it undiluted, and he will not usually 
increase the amount of fluid given beyond two pints until the acute 
symptoms begin to abate and the urine to clear. 

As the patient improves he will be given less-diluted milk, then Benger’s 
food, and other milk foods and drinks and gradually be allowed milk 
pudding, bread and butter and other cereals, and when the urine has 
become quite clear and the temperature is normal and the mouth clean, 
a little fish or chicken may be allowed. As a rule salt is not given, and very 
little protein allowed, red meat being altogether prohibited until the 
patient is beyond the convalescent stage. Bearing in mind the necessity 
for keeping the patient warm and encouraging his skin to act freely, all 
fluid food will be given as hot as he can be persuaded to take it throu^out 
his illness. 

Bowels. One of the principles of nursing mentioned above is the necessity 
of keeping the bowels acting regularly, and it is desirable to obtain at 
least two fairly fluid stools a day. In many cases aperients will usually have 
to be employed for this purpose, and either s^ne aperients, jalap, or 
liquorice powder may be found effective. When attending to the ne<rfs of 
the patient in this respect another valuable nursing opportunity arises — 
the bedpan should be thoroughly warmed. When the patient is washed 
locally after the use of the bedpan, the water used must be hot, and he 
should then be given a hot drink and tucked warmly up agaiin. 

Mouth. The condition of the mouth needs constant attention when the 
patient is acutely ill, and it should be kept as clean as possible. 

Drugs. Very few drugs will be employed in the treatment of acute 
nephritis; practically all drugs have to be eliminated by the kidneys and . 
for this reason are contraindicated. The necessary aperients have been 
mentioned; in some instances diaplwretics will be employed to make the 
sk^ act frt^y; the most powerful one is pilocarpine, front i /8th to i /4th 
grains administered by hypodermic injection; ammonium acetate is 
another, but this drug is mildly diuretic aJso in its action and diuretic drugs 
which will stimulate the work of the kidneys are definitely contraindicated 
in the treatment of acute inflammation. 

Whenever pilocarpine is ordered as a diaphoretic in the treatment of 
acute nephritis, it is primarily the business of the muse to see that h<u 
patient is so prepared that the very best effect is obtained; and, as this 
drug is a cardiac depressant, she must also be on the look-out for any 

symptoms of this. . .„ . - 

Before Ac drug is administered, since when given it will act m from 10 
to 1 5 minutes, the patient should be wrapped in hot Uankets and artificial 
heat ai^ed, either several hot water bottles or an electric cradle being 
used; a small basin should also be provided, as pilocarpine also acts m a 
sil^ogue, the activity of &e salivary glands, and the patient 



400 THE ORGANS OF THE URINARY TRACT 

should be encouraged to allow the excessive secretion to run out of his 
mouth. Hot drinks should be given a few minutes after the pilocarpine, all 
treatment being aimed at getting the very greatest amount of diaphoresis. 
A nurse should stand by the bedside and be prepared to wipe perspiration 
fi-om the brow and face, using a warm towel for this. It is useful to sponge 
the body with hot water, about i J-2 hours after the drug was first given — 
thus ensuring that the patient is not disturbed whilst it is acting — and the 
hot sponging afterwards may induce further diaphoresis. 

Other treatments which may be ordered for the production of efficient 
action of the skin arc hot air and vapour baths, and hot wet or hot dry 
packs. 

CHRONIC NEPHRITIS 

Chronic parenchymatous nephritis, or chronic tubular nephritis 

is characterized by slightly diminished minary output; the urine contains 
a great deal of albumin, and casts and sometimes blood. As the end 
pr^ucts of protein metabolism are not retained in the blood, there is no 
reason for limiting protein in the diet: on the other hand, the patient is 
constantly losing valuable protein in the form of albumin in his urine, and 
his blood becomes poor and he is anaemic, therefore a high protein diet is 
indicated, such as that described in the section dealing with dietetics 
on p. 279. 

In the general nursing care of these patients they need rest, and may re- 
quire to be kept in bed until the general condition and the anaemia can 
be improved; the skin tends to be dry, and they should therefore wear light 
woollen clothing and sleep between blankets and have a hot water bottle 
or two in their beds. Their diet should contain liberal protein material. In 
many instances oedema is present, and this necessitates a limitation of 
fluid and salt, but as the general condition improves the oedema often 
gets less or disappears. Diuretics and diaphoretics arc frequently employed. 

As patients with this type of nephritis arc subject to intcrcurrent in- 
fections — colds, influenza and bronchitis — they should be protected from 
chills and not allowed to become tired or worried or be harassed in any 
way. 

Chronic interstitial nephritis is a more serious condition ; the urine is 
often much increased in quantity and, although it may only contain a 
trace of albumin, the function of the kidneys is definitely and often 
seriously impaired. The large quantity of pale urine which is being passed 
has a low specific gravity because it is not concentrated, demonstrating 
that the kidneys are failing to concentrate their secretion, as they should 
do. Nurses are often questioned as to the seriousness of kidney disease, and 
they must remember that patients speaking to them about this disease 
should be advised to consult a physician. One point they should recollect 
is that disease of the kidney may have far-reaching and serious effects on 
the heart and other organs of the circulation. 

In chronic interstit^ nephritis, for example, the waste products of 
protein metabolism are not being excreted, but are retained in the blood. 
This type of chronic nephritis is associated with d^eneration of ^ blood 
vessels (arteriosclerosis) and with a high blood pressure, and consequently, 
sooner or later, the heart will suffer strain, it will beccane enlarged and 
hypertrophied, and cardiac failure will eventually occur. In the meantime, 
because the arteries are degeno-ated, rupture may occtir, cerebral 



CHRONIC NEPHRITIS 4OI 

ha^orrhagc may take place (for example), or epistaxis, haematurla or 
retinal haemorrhage. 

A patient with chronic interstitial nephritis docs not usually discover 
that he is ill until the condition is fairly well advanced, when he may 
complain of nausea and loss of appetite, or headache and noises in the 
head, or that he has to get up a number of times in the night to pass urine. 

Treainunt. At the outset the function of kidney and heart will be in- 
vestigated; the pK>asibility of the existence of any toxaemia or septic focus 
which might be a contributory cause will be considered, and for a time 
the patient may be kept in bed; but, once his general health is established 
at a reasonably high level, he will be taught to live a quiet, rather un- 
eventful life. The advice given him will be similar to that for a case of 
hyperpiesis (see p. 358), he should rise late and retire early, have a day in 
1^ each week, and rest for 2 hours every afternoon;- his diet should be 
light, red meat ought not to be taken, alcohol and coffee avoided and weak 
tea taken only in moderation. He should have at least one good action of 
the bowels each day and take a mercurial purge or saline aperient once a 
week. 

URAEMIA 

Uraemia is a condition of poisoning due to the retention of the waste 
products of protein metabolism, because the kidney is unable to eliminate 
them; it is called uraemia, although urea is not poisonous, because the 
quantity of urea in the blood can be taken as an estimate of the amoimt 
of other, more poisonous, nitrogenous waste products. 

Uraemia may arise whenever the tissue of the kidney is inflamed or 
degenerated, provided that its function of eliminating waste products is 
impaired; it may come on rapidly, as occurs when it complicates acute 
nephritis or poisoning by carbolic acid, or it may come on more gradually 
as when the function is being gradually interfered with because the urinary 
output is obstructed as in cases of prostatectomy, partial blockage of the 
ureters or hydronephrosis. 

The symptoms imy occur gradually or more suddenly; those which 
characterize nephritis may be present, such as a hot dry skin, rise of 
ten^raturc, nausea, vomiting, headache, and malaise; the urine may be 
loaded with albumin and blood, or diminished, or entirely suppressed; 
the pulse may be rapid, it may also be full and bounding, tliere may be 
dyspnoea and stertorous breathing, or the Cheyne-Stokes type of breathing. 

Other symptoms more directly affecting the nervous system include 
twitchings, fits and convulsions, paralysis, stupor and coma, insomnia, 
delirium and mania. There is no rule about these symptoms, as in some 
instances a patient may be in stupor, while in other cases he may have fits 
and convulsions. 

Treatment and Nursing. The nursing care in uraemia is similar to 
that described in acute nrahritis. In addition, any other symptoms which 
arise require treatment. The general lines^of treatment aim at relieving 
the tdood of poisons by making the skin'and bowels act more freely; 
diuretics are rarely employed and, when used, mild ones are preferred su^ 
at ammonium acetate and potassium citrate; in cases with a marked degree 
of suppression pilocarpine is ordered. 

Set is similar to that ordered for acute nephritis; cases of marked 



402 THE ORGANS OF THE URINARY TRACT 

plethora and cyanosis are temporarily relieved by venesection; lumbar 
puncture may be valuable in relieving oedema of the brain and so de- 
creasing intracranial pressiue, and .it is also employed occasionally for the 
prevention of uraemic fits. During a fit or convulsion it is essential to 
protect the patient from injury, and a gag or wooden wedge should be put 
between his teeth to prevent him from biting his tongue; fi-equent con- 
vulsions become prostratii^ and may be controlled by morphia or in- 
halations of chloroform. Cheyne-Stokes’s breathing may be relieved by 
inhalations of carbon dioxide 7 per cent, in oxygen. 

Local treatment in the form of applications of heat or dry cupping the loins 
over the kidneys may relieve congestion in those organs, and general 
applications of heat may be ordered to assist the action of ^e skin. 

Restlessness and twitchings may respond to sedatives such as bromide 
and chloral. Inhalations of oxygen may be useful in relieving restlessness. 

When vomiting is persistent it will have to be controlled; starvation for 
24-36 hours and ^e administration of minim doses of iodine in water may 
help. 

INFECTION OF THE URINARY TRACT 

Pyelitis and ^stitis are the conditions most commonly met. Either 
condition may be acute or chronic. 

The commonest cause is infection by bacillus coli but urinary infection 
may be associated with chronic suppuration of the kidney, ren^ tubercu- 
losis, calculus, obstruction to the urinary output and malignant disease. 

In the care and treatment of infection of the urinary tract careful in- 
vestigation of the urological system is very important. This includes X ray 
of the tract, pyelo^phy and cystoscopy, and the various tests of renal 
function, such as me urea clearance and urea concentration tests. (For 
full information see investigations and tests on pp, 212-14.) 

PYELITIS 

Inflammation of the pelvis of the kidney is usually due to infection by 
bacillus coli though it may accompany other conditions. 

In acute pyelitis the onset is sudden with a rise of temperature and 
marked toxaemia; the patient suffers considerably from malaise, the 
temperature runs a continuous course' and rigors are not uncommon; 
the tongue is dry and covered with brown fur, mere is marked thirst and 
loss of appetite. 

Local symptoms may be very indefinite, as a rule there is aching pain in 
the region of the loins — when the right kidney only is affected the con- 
dition may be mistaken for appendicitis. There may be some fmjuency 
of micturition, but this is not invariable. 

The urine is highly acid and has a characteristic shimmering opales- 
cence; it has a slightly fishy odour, usually contains some albumin and has 
a deposit of pus cells and casts. On bacterial examination it is found to 
contain quantities of bacilli coli. 

The medical treatment of this infection includes rest in bed, the 
administration of bland fluids, the provision of a very fight diet, oidy 
diluted milk being given whilst there is pyrexia; and, as long as the in- 
flammatory condition persists, low protein diet with easuy diginted 
cartmhydrates should be administered, unless the diet is a special feature 



PYBLITIS 403 

of the treatment as in the administration of a ketogenic diet, mentioned 
on p. 289. 

The pyrexia present, and the symptoms associated with this, need 
treatment for their relief. The urinary output should be measured and the 
mine tested for the presence of albumin and pus; bacteriological tests 
should be employed at regular intervals, in order to estimate Ae rate of 
progress of recovery. 

Any special treatment carried out aims at destroying or inhibiting 
the grovnth of organisms in the urine, and to raising the resistance of the 
patient. Mmy urinary antiseptics are employed^ and hexamine may be given 
in doses of from 5 to 15 grains, three times a day; it is usually combined 
with acid sodium phosphate in 1 5-grain doses, as hexamine will only be 
effective as an antiseptic in an acid medium. 

Pyridium, pyridine and acriflavine are other examples of urinary 
antiseptics. 

Another plan made use of is to render the urine alternately acid and 
alkaline; the patient may be given potassium citrate for 10 days or so and 
then, when the urine is ^kaline, he is given the mixture of hexamine and 
acid sodium phosphate previously mentioned. This method is employed 
by those who consider that the bacillus coli thrives least well in a changing 
medium. 

Mandelic acid treatment is an alternative method. It can be used in acute 
and chronic cases. Three grammes of mandelic acid combined with a dose 
of 1 1 grammes of sodium bicarbonate in solution is given three times a day. 
The amount of fluids taken is limited to 2 pints a day in order to obtain 
the concentration of mandelic acid in the urine which is known to produce 
the best effects. 

The urine is kept at a definite degree of acidity (about /»H 5 '4) by the 
administration of ammonium chloride, 2 grammes, three times a day. 
In many instances it has been found most successful when the mandelic 
acid is given before and the ammonium chloride after meals. The amount 
of ammonium chloride given in the day is regulated by the acidity of the 
urine, and the nurse in charge of the patient must be prepared to rniake the 
necessary test as follows: 

Two cubic centimetres of urine are put into a test tube, five drops of 
methyl red are added, when a slightly pink colour will show that the urine 
is of the correct acidity; if too acid, the colour will be deep pink, but if too 
alkaline it will be pale yellow. 

The nurse should know that large doses of ammonium chloride may 
irritate the kidney, and if she discovers albumin in a previously normal 
urine, this should be reported at once. She shbuld notice whether the 
patient complains of nausea, vomiting or diarrhoea. 

In the majority of cases the nurse will note that improvement occurs 
after a flsw days, or between 10 and 14 days from commencement of the 
treatment, that the frequency of micturition is less and that the discomfort 
disappears. Bacteriological examination will demonstrate the improve- 
ment in the condition of the urine. 

The use of preparations of sulphanilamide (see p. 327) has recently been 
employed wiA good success. 

In Aortic pyelitis vaccines are employed in addition— either stock or 
autogettotis— in otderito try and raise the resistance of the patient to 
bacillus coli ii^ections. 



404 


THE ORGANS OP THE URINARY TRACT 


CYSTITIS 

Inflanunation of the urinary bladder may be due to infection by the 
bacillus coli, staphylococcus, streptococcus, gonococcus, tubercle baollus 
and bacillus typhosus. 

Predisposing causes arc a chill, and retention of urine or incomplete 
emptying of the bladder as occurs in enlargement of the prostate ^nd 
in men and in some gynaecological and obstetric conditions in women. 

In acute cystitis there is severe pain over the bladder in the hypogas- 
ric region, and the frequent passage of small quantities of urine — ^a 
drachm or two every five minutes, accompanied by pain — is a most 
distressing symptom. 

The urine is thick and contains large quantities of mucus and pus; it is 
acid when the condition is due to baciUi coli but alkaline when due to 
other causes. There may be a rise of temperature but this is not invariable 
and in many cases the constitutional symptoms are slight. As the days pass 
the patient becomes tired and weary because of the pain and the inability 
to sleep owing to the marked frequency of micturition. 

Treatment. The patient is kept in bed and hot applications arc applied 
over the bladder. The diet should be light and plenty of bland fluids 
should be given; the bowels must be regulated. When the urine is acid the 
treatment by drugs is the same as described in pyelitis; when it is alkaline 
acid sodium phosphate is given to reduce the alkalinity. 

In chronic cystitis similar measures are taken and in addition the bladder 
is irrigated with a mild antiseptic, and vaccines are employed. 

DISORDERS OF MICTURITION 

Disorders of micturition may be dealt with under the following headings 
— 'frequency, incontinence, enuresis, retention and dysuria. 

Frequency of micturition is usually attributable to some disorder or 
disease of the urinary tract, and in some cases to lesions outside the tract 
which arc irritating it. In a great number of conditions it is due to an 
irritable urine, and in others to polyuria. Examples of conditions of the 
urinary tract giving rise to frequency are pyelitis, cystitis, and urethritis. 

Incontinence means the involimtary expulsion of urine from the 
bladder. This must not be confused with an urgent desire to pass uiine, 
which will cause urine to be involuntarily passed if the patient has to wait 
long. Another condition allied to incontinence is the passing of a few 
drops of urine under conditions such as stress and strain, as when intra> 
abdominal pressure is increased; this may happen when sneezing, 
laughing or coughing. 

True incontinence, which is entirely involuntary, may mean that the 
sphincter muscle is completely relaxed, the urine dribbling away as it is 
secreted and the bladder remaining quite empty. 

In some cases, however, there is spasm of the sphincter urethrae and 
urine is retained in the bidder which is always distended, only the over- 
flow dribbling away. This occurs in injuries to the brain and spinal cord, 
and is best described as retention with overflow. 



DISORDERS OF MICTURITION 405 

Enuresis is the term used to describe incontinence which may be 
diurnal (by day) or nocturnal (by night) — ^it usually occurs in children, and 
is due to the incomplete establishment of voluntary control. It may be 
that control once established has been lost; but in most cases the history 
will be that the child or adolescent has tilways been incontinent. 

In considering the treatment of enuresis it is essential to look for other 
factors which may be contributory causes such as the presence of worms, 
a highly acid urine, the existence of enlarged tonsils or adenoids, or any 
other condition which causes a child to sleep lightly. 

The nurse is very intimately concerned with the treatment of this type 
of incontinence. The diurnal type is easily dealt with by getting the chUd 
to empty his bladder every two hours, or every hour if necessary. Nocturnal 
enuresis is more difficult to treat, but it is very important that all com- 
mission should pass unnoticed, uncommented on, and all omission be 
highly praised. Some recommend the use of a hard mattress, waking the 
child say at 10 o’clock to pass tuine, limiting any fluid intake after 5 p.m.; 
but in many cases these measures have not been found of any use. The 
child usually grows out of the condition, and in the meantime psycho- 
logical treatment indicated above is probably the best to use. Belladonna 
may be ordered to help control the activity of the bladder. 

Retention of urine means that urine is retained in the bladder, which 
becomes distended and on examination can be felt above the symphysis 
pubis. This condition gives rise to discomfort and pain, and it is very 
important that the nurse should not confuse it with suppression of urine 
as described on p. 398. 

The causes of retention are numerous. There may be interference with the 
nervous mechanism; nervousness and hysteria may cause spasm of the 
sphincter of the urethra; organic lesion of the brain and cord, especially 
when this occurs as the result of an injury, may have a similar effect; 
interference with the sympathetic nerves following operations on ab- 
dominal and pelvic organs, depression of the micturidon centre following 
general anaesthesia, the use of certain sedative drugs, shock — ^which 
depresses all the vital centres, including those governing micturition — 
pain, as in urethritis and cystitis, when the patient inhibits micturition, 
and eventually the reflex is interfered with and retention occurs — any 
of these may be a cause. Decrease of intra-abdominal pressure may arise 
when the abdominal muscles have been recently stretched, and this may 
occur immediately after childbirth, or after the removal of a large quantity 
of intraperitoneal fluid by tapping, or after the removal of a large ovarian 
cyst. Diminished tone of the musculature of the bladder may be associated 
with debility, severe anaemia and senility. Pressure externally on the 
urethra or neck of the bladder, as may arise from the presence of tumour, 
or be due to enlargement of the prostate gland. 

The nursing treatment for the relief of retention. From the list of causes given 
above, it can be seen that in the majority of instances the nurse may be 
able to effect relief without resorting to catheterization. The point to 
remember is that the distention of the bladder has probably suppressed 
the normal impulses of micturition, so that this reflex is temporarily out 
of control. 

The following measures may be tried — the giving of hot or cold drinks 
which, slightly altering the tension by adding quiddy to the contents of 



4o6 the organs op the urinary tract 

the bladder, may stimulate the reflex; altering the patient’s position in 
bed, encouraging him to try to micturate while lying on his side, if he 
cannot do so while lying on his back; and a male patient may be 
allowed to kneel in suitable circumstances upon the bed to pass urine. 

The addition of a little warm water to t^ bedpan, or pouring a Uttle 
warm water over the vulva in the case of a woman — ^it is important to 
measure the amount of any water put into the bedpan in order to ascertain 
how much urine has been passed — turning on a tap in the vicinity may 
act by suggestion; applications of warmth over the distended bladder — 
any of these may perhaps give relief. 

The patient’s feet should be quite warm, and he might be allowed to 
wash his hands, as moving them about in the water may assist in re- 
laxation. The administration of a hot bath, if the patient is allowed to go 
to the bathroom, has been found particularly useful in male cases, es- 
pecially when retention is due to some painful condition, as in orchitis. 

The administration of an enema may be effective. This acts because it 
makes the patient empty the bowel, and it is most valuable in the case of 
women patients, since, in the female, contraction of the pelvic diaphragm 
by the act of defaecation causes movement of the other sphincters opening 
into it. 

Dysuria, or difficulty of mictiuition, is a term used to indicate the fact 
that pain accompanies the act; it may be due to some diseased condition 
of the bladder and urethra which leads the patient to attempt to inhibit 
the desire to micturate. In such instances, allowing the patient to sit in a 
hot bath and pass urine in the water is often very efficacious. The ad- 
ministration of liberal amounts of bland fluid, by diluting the urine and so 
possibly rendering it less irritating, is another way in which the nurse 
may help. 



Chapter 26 

Diseases and Disorders of the Nervous System 

Introduction: Symptoms of an upper and lower neurone lesion — Hemiplegia — 
Paraplegia — Disseminated sclerosis — Infantile paralysis — Bell's palsy — Neuritis — 
Syphilis of the nervous y>stem — cerebral syphilis, locomotor ataxia, general paralysis 
of the insane — Inflammation of the brain and meninges — Meningitis, encephalitis 
lethargia — Irfections of the spinal cord — transverse myelitis — Functional disorders — 
Neuralgia — Hysteria — Paralysis agitans — Chorea — Anorexia nervosa — P:ychoses 
and Neuroses — Fits and convulsions — Epilep^ — Hysterical fit — Apoples^r—Coma 

D iseases of the nervous system may be divided into : ( i ) those affecting 
the central nervous system, the several parts of the brain and the 
spinal cord, and (2) those affecting the nerves given off from the 
central parts, the periphersd nerves. They are said to be organic when a 
definite lesion exists, and functional when no changes take place in the organ. 

Nervous diseases are also very commonly classified according to the 
neurone affected — a neurone is a nerve with its cell, dendrons and axon; 
some of these neurones function in the central part where they are called 
upper motor or sensory neurones; others in the peripheral portion arc called 
lower motor or sensory neurones. 

A nervous disease which affects the function of the muscular system is 
characterized by changes in the behaviour and fiinctions of the muscles 
supplied by the disordered or diseased nerves, and it has therefore been 
found convenient in describing some of the nervous diseases to classify 
them as upper or lower motor neurone lesions, according to the symptoms 
which are manifesL 


Symptoms 

Wastit^ of 
Muscle 

Rigidity of 
Muscle 
Reflexes 


Electrical 

realms 


In lesions of the upper motor 
neurone 

Very slight, and only so 
fiu* as due to disuse of 
the muscle 

The limbs tend to be very 
rigid 

Deep reflexes exaggerated, 
knee and ankle jerks 
very brisk; the plantar 
reflex gives an extensor 
response (Babinski’s sign) 

No change, the reactions 
are present as in a nor* 
mal muscle 


In lesions of the lower motor 
neurone 

Very marked, so much so 
that in children the limb 
will cease to grow 
None — but complete 
flaccidity present 
Reflexes abolished 


Reactions always modi- 
fied. In complete le- 
sion the muscles fail to 
react to faradism and 
react only sluggishly to 
galvanism. (This is 
c^ed the reaction 
degeneration) 


407 



4o8 the nervous system 

Symptoms In lesions of the upper motor In lesions of the lower motor 

{continued) neurone neuroru 

Deformities Rigidity of muscle is ac- Deformities occur owing 
companied by contrac- to the unopposed action 

tures; the arm becomes of healthy muscles 

flexed and adducted and 
the leg flexed at the 
knee and adducted at 
the hip joint 

The articles shown in illustration (fig. 233, p. 694) are those which will 
be required for the examination of the nervous system. 

The best examples of disease of the upper motor neurones are hemi- 
plegia, paraplegia and disseminated sclerosis. 

HEMIPLEGIA 

Hemiplegia is paralysis of one side of the body, face, arm and leg. It is 
due to a lesion of disease, injury or cerebral haemorrhage on one side of 
the brain which produces paralysis of the opposite side of the body. 

The onset may be sudden with an apwplectic seizure in which the patient 
becomes immediately unconscious and lies breathing hcavUy with a full 
bounding pulse, noisy respirations and flushed face (sec also p. 430); 
or the onset may be more gradual, when signs of paralysis come on slowly. 
The paralysed parts are limp and flaccid for the first day or two, and then 
the symptoms characteristic of an upper motor neurone lesion are mani- 
fested by rigidity of muscle, exaggerated reflexes and a tendency to 
contractures. If the patient protrudes his tongue it will be inclined to- 
wards the paralysed side; he may have difficulty in speaking and in ex- 
pressing what he wishes to convey, and this is termed dysphasia. The 
speech area may be involved on the left side of the brain in the case of a 
right-sided hemiplegia, and the patient be unable to speak, which is 
termed aphasia. 

Treatment and nursing. The patient should be put to bed, with the 
head of the bed slightly elevated; a cold application may be applied to 
his head and his feet should be kept warm. A four-hourly record of the 
temperature, pulse and respiration rate should be kept; the temperature 
may rise. The bowels should be kept active by the use of aperients which 
will produce several watery stools for the firat few days; then two soft 
stools a day. The urine should be tested, and the bladder watched for any 
tendency to retention of urine. 

The patient is usually an elderly person, and there is therefore con- 
siderable danger of hypostatic pneumonia; the position in which he lies 
ought to be changed at least every 2 hours in order to obviate this. As a 
rule his breathing will be fairly deep; but, when he is moved, he should be 
well disturbed in order to m^e him breathe deeply and so ventilate his 
lungs; this requires caution, as injudicious handling may cause a recur- 
rence of the cerebfal haemorrhage which may have caused the hemi- 
plegia. 

The skin requires regular attention in order to prevent the formation 
of bedsores; the patient’s mouth should be kept dean and, as it is likely 
to be dry, it shotild be moistened frequently. Au soon as he wishes he may 



HBM1PI.E01A 

have small drinks of bland fluids but, for fear of raising the blood pressure 
in cases of an apoplectic character, the quantity given should be less than 
3 pints during each 24 hours. When the patient is able to take food, light 
diet will be given — but red meats, soups made from meat; stimulants, 
including tea and coffee, should be avoided. The patient may require to 
be fed; if one side of the face, including the movements of the tongue, is 
paralysed, he may have diflSlculty in mastication and swallowing, and this 
must be taken into consideration when feeding him. 

The patient should be kept quiet and not allowed to get excited, to 
indulge in attacks of violent coughing, or sneezing, to move himself 
violently about in bed or perform any other action likely to cause even a 
slight rise in blood pressure. 

The position of the limbs in bed should be observed and deformities 
prevented from occurring; the affected arm should be abducted from the 
side of the body by means of the insertion of a wedge-shaped pillow in the 
axilla. The forearm should be extended and supinated and the wrist ex- 
tended a great many times a day, in order to prevent the deformities of 
flexion and pronation of the forearm with flexion of the wrist which so 
easily occur in cases of hemiplegia. The affected lower limb should be 
kept in good alignment— not too straight. The tendencies to be counter- 
acted here are flexion of the knee, plantar-flexion of the ankle and ex- 
ternal rotation of the thigh. Splints or sandbags may be used to correct 
the position in which the limb lies. 

As recovery takes place the affected limbs will be massaged and passive 
movements of the joints carried out, encouraging active movements as 
soon as possible. 

A nurse should keep in mind any cases of hemiplegia she may have seen 
walking in the street with the characteristic gait and attitudes which are 
apt to persist unless care is taken in the prevention of deformity and the 
re-education of the weakened groups of muscles to overcome the con- 
traction and rigidity of stronger groups. 

llie typical gait and attitude mentioned arc, that the patient carries 
his afflicted arm closely adducted to the side of the body, with forearm 
flexed and pronated. As he walks, in order to avoid tripping over the 
affected leg, he leans over towards his sound side and throws the affected 
limb out in a circle in order to bring it to the ground in front of him. This 
necessitates great effort, in addition to being a deformity and attracting 
notice in the street. 


PARAPLEGIA 

Paraplegia is paralysis of one half — the lower half — of the body. It is 
usually due cither to pressure from an injury as in the case of a fractured 
spine, haemorrhage into the spinal cord, the presence of a tumour on the 
cord, or collapse of the diseased bodies of the vertebrae in Pott’s disease. 

As the result of this pressure the lower limbs are paralysed and the 
sphincters of the urethra and anus are involved; there may be retention, 
or incontinence of urine, and incontinence of faeces is frequently present, 
though the patient is usually constipated. 

In the nursing care the aims of treatment are to prevent bedsores and 
infection of the bladder; the details of the care of a similar case will be 
found in the account given on p. 603 of the nursing of a patient with a 
fractured spine, which is one of the causes of paraplegia. 



410 


THB NERVOm SYSTEM 


DISSEMINATED SCLEROSIS 

Disseminated sclerosis is a fairly common organic disease of the central 
nervous system. It occurs in persons, of both sexes, between the ages of 
1 8 and 35, and is characterized by scattered patches of degeneration over 
the brain and spinal cord — hence the term disseminated. 

Symptoms. There is usually §ome paralysis with rigidity of the muscle, 
exaggerated reflexes and a tendency towards occurrence of contractures; 
at &^t the paralysis may be temporary, as one of the chief characteristics 
of disseminated sclerosis is that it is marked by remission and relapses, but 
in the majority of patients the spastic paralysis will, eventually, become 
permanent. 

Other characteristic symptoms include tremor of the hands, and un- 
steadiness in walking — ^in some cases a subject will consult a physician 
because he falls down in the street for no apparent reason. Eye changes 
will sometimes occur and the patient may complain of double vision or be 
found, on examination, to have some degree of nystagmus — ^which means 
that there is an involuntary twitching of the eye, which may consist of 
either coarse or fine oscillating movements. 

Subjects of this disease have a particularly happy temperament; they 
are obliging, cheerful members of the community and smile a great deal. 

Treatment and nursing depend, as far at least as the latter is con- 
cerned, on the condition of the patient when he is seen; a badly paralysed 
subject will be nursed in bed and the precautions against bedsores be 
taken; it is customary, however, in all cases to use massage and re-educative 
exercises in order to keep the patient an effective member of society for as 
long as possible. Apart from this, the patient should be advised not to get 
overtired and, if he sufiers from intercurrent infections such as colds and 
slight influenza, he should remain in bed and take a long rest as con- 
valescence. In many cases, remissions occur and the patient can keep well 
for long periods together, while less fortunate ones will have more frequent 
relapses. 

A course of arsenic is usually prescribed. Treatment by protein shock 
therapy and by malarial therapy has been tried. 

The best examples of disease of the lower motor neurones are infatUUe 
paralysis, Bell's pal^ and neuritis. 

INFANTILE PARALYSIS 

Infantile paralysis, called also acute poliomyelitis, is an acute lower motor 
neurone di^se which affects the motor cells in the anterior horns of the 
spinal cord and results in destruction of some of the nerve cells and serious 
injury to others. It is due to a specific orgaiusm which is carried in the 
nasopharynx. It affects children and young people but adults also may 
be affected; the disease is sporadic in this country, though epidemics of it 
have occurred. 

The onset of the disefise may be severe with a great deal of pain, a rise in 
temperature, severe headache, and marked malaise; or it may be more 
gradual, when slight paralysis is first noticed. 

Treatment and nursing. The disease is infectioiu, it may be conveyed 
to others or contracted by those attending to the patient, and to avoid 



INFANTILE PARALYSIS 4II 

these tragedies the simide methods of bed isolation, described on p. 464, 
are usually considered advisable for the first 4 weeks of illness. 

At the outset the patient may have a great jleal of pain and resent any 
handling of his limbs; if this is so, they should be wrapped in cotton wool 
and very gently touched. The limbs must be kept in such a position that 
deformities cannot occur, though it may be difficult at first to determine 
which groups of muscles are affected, and it is advisable to keep the limbs 
in a fairly neutral position for a time, so that neither one group nor 
another will be unduly stretched. The patient should be nursed lying flat 
in bed, or on a plaster of paris bed, in order to keep the muscles of the 
trunk at rest. No massage or electrical treatment is permissible for the 
first two months, as during the acute inflammatory stage it would only 
irritate the already overimtated nerves. Lumbar puncture is performed 
in the acute stage for the relief of headache and intrathecal administration 
of human serum from convalescent cases has recently been employed as a 
curative measure. 

The duration of rest in the treatment of infantile paralysis is long, and 
in adult patients particularly this is found very trying and as much as 
possible should be done to keep the patient cheerful during this irksome 
wait, when he is moreover troubled by uncertainty as to whether he may 
or may not recover completely. 

As soon as possible some light splint will be adapted to the affected 
parts and the patient encouraged to get up and move about; massage and 
electrical treatment will be prolonged for as much as two years, as re- 
covery often takes place after a very long time. Later, when the resultant 
recovery is not complete, surgical measures may be considered for the 
sake of securing better functioning by the fixation of joints and the trans- 
plantation of healthy muscles to take the place of, and perform the offices 
of, some which will not recover. 

BELL’S PALSY 

Bell’s palsy was described by Sir Charles Bell, the founder of the 
Middlesex Hospital Medical School. It is a lower motor neurone paralysis 
— affecting the facial nerve, the seventh cranial, which supplies the muscles 
of expression of the face. It may be due to exposure to cold. 

Symptoms. At the onset slight pain may be complained of behind the 
car and down the side of the neck; the affected side of the face is limp and 
quite expressionless; but, as the muscles on the other side of the face have 
no opposing muscles to balance their action, the latter — the sound side — 
is drawn up in a most grotesque manner. The eyelids on the paralysed 
side droop, the corner of the mouth is relzoced and saliva dribbles out of it; 
the folds and creases and wrinkles are aill obliterated. 

Treatment and nursing. The eye should be bathed and kept covered, 
the comer of the mouth supported by means of a silver hook placed inside 
the corner of the mouth and fastened up over the ear to prevent the 
muscles from being constantly dragged down by the weight of gravity. 
This hook must be kept vci^ clean and the mouth should be cleaned; 
eating may present some diflaculty, but the actual muscles of mastication 
are not included in the paralysis since these are supplied by the filth and 
not the seventh cranial nerve. 



412 THE NERVOUS SYSTEM 

Massage and electrical treatment will be employed when the initial 
inflammatory stage has passed; as soon as active movement is permitted 
the patient should be taught to use his muscles by trying to smile, whistle 
and frown, in front of a mirror. 

NEURITIS 

Neuritis is inflammation of a n^^t've fibre and its covering. The condition 
is described as polyneuritis or multiple peripheral neuritis when it exists on both 
sides of the body, affecting a number of nerves. Alcoholic neuritis is an ex- 
ample of this type. 

In interstitial neuritis one or two nerve trunks only arc affected; ex- 
amples of this variety are sciatica and brachial and intercostal neuritis. 

The symptoms and signs of neuritis include pain, tenderness and 
swelling over the affected nerve trunks, alterations in sensation — such as 
tingling and numbness — wasting of muscle with loss of tone, and dimin- 
ished tendon reflexes and paralysis. 

The treatment includes investigation for any possible cause — ^thc 
presence (for instance) of a septic focus in the body, such as septic tonsils, 
teeth, gallbladder, appendix, or the existence of colitis. These factors 
should be treated. 

Meanwhile the distressing symptoms of neuritis require local measures 
for their relief During acute pain rest is necessary, applications of heat 
may give relief and soothing analgestic preparations may be employed for 
this purpose also. 

In the nursing care of a neuritis case it is essential to discover the position 
in which the patient can lie most comfortably, and also to observe the 
effect of the various local treatments employed, and to find out which 
gives most relief and which may be contraindicated since it seems to 
irritate the condition. 

The patient should be very gently moved; the bed should be free from 
creases and the weight of the clothes should not rest on the painful parts. 
Wrapping the painful parts in cotton wool will sometimes be found 
soothing, at other times supporting them on pillows or splints or between 
sandbags may bring relief; in a few instances, where no relief seems to be 
obtainable, elevation of the foot of the bed and the application of slight 
extension to a painful lower limb may help. 

The diet will as a rule be specially ordered and it is the duty of the nurse 
to make it as appetizing as possible; a patient who is in pain is disinclined 
to eat, he is depressed and every little surprise and change of any kind 
will, by awakening interest, help to relieve the painful monotony of his 
present existence. 

Diseases of the sensory neurorus cannot as readily be classified into upper and 
lower as arc those of the motor system just described. Three relays of 
sensory nerves convey impulses from the periphery to the brain. One of 
the best examples of ^sease of sensory neurones is locomotor ataxia. 

SYPHILIS OF THE NERVOUS SYSTEM 

Syphilis is described on p. 535* One of the most serious results of this 
disease, and the one which is most disabling, is manifested in the diseases 



SYPHILIS OF THE NERVOUS SYSTEM 413 

of the nervous system which are due to it. These are cerebral syphilis, loco- 
motor ataxia and general paralysis of the insane. 

Cerebral syphilis may be manifested by inflammation of the cover- 
ings of the brain — the meninges — or the arteries which supply the brain 
with blood may be affected. 

A variety of symptoms may be present including severe headache, 
epilepsy, hemiplegia, double vision, general mental changes characterized 
by loss of memory and irritability of temper. This type of case is treated 
with the usual antisyphilitic remedies, novarsenobillon (arsenic) and 
mercury. 

LOCOMOTOR ATAXIA 

Locomotor ataxia is a disease of the sensory neurones. It is also described 
as tabes dorsalis. This disease occurs some years after syphilitic infection, 
in what is known as the tertiary stage of syphilis. 

Symptoms. Locomotor ataxia is characterized by shooting pains in 
the limbs and by lack of co-ordination of voluntary movement; the disease 
does not affect the motor nerves, sensation is affected and in the later 
stages of the disease the patient loses the sense of the position of his body 
in relation to other things, such as the floor or his chair, and fails to be able 
to co-ordinate his movements even so far as to touch some part of his body, 
his nose for example, without groping over his face with his hand in order 
to find it by feeling for it. 

Other symptoms and signs include smallness of the pupils of the eyes 
and their failure to react to light. As the sensory portion of the reflex arc 
is not functioning there is loss of deep reflexes. The patient’s gait becomes 
very characteristic. He behaves like a high-stepping horse and lifts his leg 
high and then bangs his foot forcibly on the floor, swaying from side to 
side as if drunk. This is called the stamping or tabetic gait. 

As the disease progresses all these symptoms get worse. Tabetic crises 
may occur. A gastric crisis is characterized by attacks of abdominal pain 
and vomiting; a vesicle crisis by attacks of acute retention of urine. 
Charcot's joint may develop; this is a form of arthritis characterized by 
laxity of the ligaments of the joint affected which renders it weak and 
flail. The knee joints are most commonly affected. 

The treatment which will arrest the progress of the disease is anti- 
syphilitic, and arsenic and mercury are employed as described in the 
treatment of syphilis. 

The ataxia and incoordination can be very much improved by re- 
education by means of Fracnkel’s exercises, which aim at improving the 
movements, by making the patient use his eyes to see where he is putting 
his hands or feet; he is taught to walk along a strip of floor, on which 
footmarks are placed, and he is expected to put his feet exactly on these 
as he walks alon^. 

Massage will improve the general tone of the muscles of the limbs; 
the patient should be warned not to allow himself to get tired; his diet 
shoidd be nourishing and he should live an easy comfortable life, and get 
as much rest as possible but he should not stop in bed, as surrender to his 
disability in this way will allow the disease to progress, and he will then 
quite quickly become a very helpless member of society. 



414 


THB NERVOUS SYSTEM 


GENERAL PARALYSIS OP THE INSANE 

General paralysis of the insane, which is an inflammatory lesion affecting 
the nerve cells in the brain, is due to syphilis and occurs in the tertiary 
stage of the disease, except in those comparatively rare cases which are 
congenital. As a rule this disease occurs between the ages of 40 and 60. 

Symptoms. The onset is characterized by mild mental symptoms, 
slight loss of memory, apparent loss of interest, inability to concentrate, 
making mistakes at work, and attacks of depression. If the disease is not 
treated, all these symptoms will become worse and the patient will 
develop delusions of grandeur — he may order expensive articles for which 
he cannot possibly pay and imagine he is somebody very great. As the 
disease progresses mental failure occurs, the patient wastes and eventually 
dies. A fit or stroke may occur during the course of the disease. 

Treatment. Antisyphilitic remedies having been found useless, all 
these patients until comparatively recently died, but it is now considered 
that a number can be cured by treatment with an induced attack of 
mal2uia. 

The malarial treatment of G.P.I. The patient is infected with benign 
tertian malaria either by allowing him to be bitten by infected mos- 
quitoes, or by infected blood given intramuscularly. After a short in- 
cubation period he develops malaria and is allowed to have eight or nine 
rigors — these occur on alternate days in the benign tertian type of malaria 
— and the disease is then arrested by the administration of quinine. 

Nursing duties during this period are observation of the patient’s general 
condition. As soon as he has been infected with malaria his temperature 
should be taken every four hours; when malaise is complained of the 
patient should be kept in bed. 

The time of the first rigor should be noted; at first the patient will be 
very cold, and during this period his temperature will begin to rise and 
should then be taken every 15 minutes; it will reach its maximum in a 
short time and, if it rises above 105° F., the patient should be sponged 
with tepid water, as such a very high temperature may be accompanied 
by delirium and will be followed by marked prostration. Aptut firom this 
precaution the nursing care of the patient during rigors is as described 
on p. 37. 

The physician may require the nurse to take a blood film when the 
temperature is at its maximum, in order that he may note the number of 
malarial parasites in the blood, which indicate the severity of the infection. 

The general condition of the patient must be carefully observed, as he 
will be weakened and rendered anaemic by this treatment; if he suffers 
from vomiting and diarrhoea or from delirimn, during the course of his 
malarial treatment, it may be necessary to stop the treatment before he 
has had the number of rigors usually permitteef. 

After the treatment he will probably be very anaemic and will need a 
liberal nourishing diet and some weeks’ rest before any improvement is 
noticed. 

INFLAMMATION OF THE MENINGES (MENINGITIS) 

The principal types of menii^tis are meningococcal, tuberculow, 
pneumococcal and streptococcal. 



INFLAMMATION OF THE MENINGES 415 

Tuberculous meningitis occurs most often in children, though any 
age may be affected; in adults it may arise as a complication resulting 
from spread of the disease from some other lesion in the body. 

The onset in tuberculous meningitis is gradual with headache, malaise, 
loss of appetite, and a slight rise of temperature. 

The stage of irritability. As the disease progresses the symptoms of cerebral 
irritation become manifest — the patient lies curled up in bed with head 
retracted and the muscles of his neck are rigid. He will cry when touched 
and resents being moved; paralysis may now be present or convulsions or 
delirium occur. 

The next stage of the disease is manifested by coma' unconsciousness 
gradually becomes deeper, and retention of urine will very likely occur. 
Many cases terminate fatally in about 6 weeks. 

The treatment is palliative ; lumbar puncture is performed to relieve 
pressure; the cerebrospinal fluid is always clear in tuberculous meningitis; 
in other types it is turbid. M and B 693 (see p. 328) has been used with 
success both in pneumococcal and meningococcal infections. 

MENINGOCOCCAL MENINGITIS 

Meningococcal meningitis is also described as cerebrospinal fever. It is due to a 
specific organism, neisseria meningitidis or neisseria intracellularis . The disease 
is of the nature of an acute infection. The organism is carried in the naso- 
pharynx; the disease is sporadic in distribution in this coimtry but epidemics 
do occur, particularly under conditions of bad general hygiene and over- 
crowding. 

The onset of the disease is usually short and acute, and the course more 
rapid than that described in tuberculous meningitis. 

The symptoms also arc similar, but more acute. There is severe head- 
ache, and the patient lies curled up on his side with head markedly re- 
tracted; he is extremely sensitive to the slightest irritation by touch, or 
sound, and also to light. His mouth is very dry and his tongue coated, his 
temperature is high and pube rapid at first; there may be paralysis, the 
pupils may be unequal and squint may be present. The mind wanders 
and the patient is delirious. Rigidity of the muscles is very marked and 
Kemig’s sign is present — this means that when the thigh is flexed the 
mark^ rigidity of the flexors of the knee prevents the knee joint from being 
extended. Wasting is marked, the patient passes urine and faeces invol- 
untarily and rapidly reaches the stage of coma. There is increase of in- 
tracranial pressure manifested by deepening coma, slowing of the pulse, 
deepening of the respirations and, unless adequate serum treatment can 
be obtained, death may occur after several we^. Some cases recover and 
are left with a pemument disability, which may be mental or physical 
in character; a few make a slow, imcomplicated recovery. 

Treatment. Sulphonamides arc now used with great success and as a 
result the period of acute disease is shortened and the prognosis is favour- 
able. Repeated lumbar puncture and the administration of a specific serum 
are also useful. 

Nursing. The nursing of meningitis is difficult, because the patient is 
acutely ill and liable to b^omc worse and, as cerebral irritation is marked, 



4i6 the nervous system 

it needs keen observation and great gentleness and patience on die part 
of a nurse who is to deal succes^lly with such a case. 

As the disease is infectious the principles of bed isolation should be eni> 
ployed, and all swabs used and all dischai^cs from the nose and mouth 
should be destroyed by burning. 

A well-ventilated room is necessary but the patient should not face the 
light. As he lies curled up in bed, sensitive even to the slightest touch, 
which in this case acts as an irritation, great care must be taken in moving 
this patient; he must not be touched by a cold hand, and should be grasped 
firmly but not roughly, the hand being imposed gently and the hold firmly 
and evenly maintained; all movement performed should be as slow as 
possible and should not be jerky but rhythmical in character. The head 
must not be moved as the slightest attempt to flex it is accompanied by 
severe pain which increases the irritation. 

As the patient is emaciated and incontinent the skin requires the 
greatest care and attention if bedsores are to be prevented; he may lie 
with a ring air cushion under his side to prevent sores from forming over 
the great trochanter; he can be turned to alternate sides but should not be 
placed directly on his back, though he may lie partially over on his back 
for definite periods provided he is supported by pillows. 

He should be sponged twice a day, and the nurse must notice whether 
warm or hot water proves least irritating to him, and use whichever seems 
most acceptable. 

The mouth requires constant care to keep it clean and moist; secretion 
which dries in the nose should be moistened and removed; in the stage of 
coma the patient will lie with his eyes open and they should then be bathed 
regularly in order to prevent the occurrence of conjunctivitis. As already 
mentioned, all swabs used for these purposes should be burnt. 

The bladder must be watched for fear of retention, and it is advisable 
to measure the urine, so that any diminution in quantity does not go un- 
marked; it should be tested regularly. The bowels must be kept acting by 
the use of aperients or enemata if necessary. The method adopted of feeding 
the patient will depend on his condition; if conscious he will be able to 
swallow; even when in a state of stupor it may be possible to rouse him to 
take sufficient fluid; but when in coma he will have to be fed artifically and 
as he requires nourishment to combat the wasting that is characteristic 
of this infection, it is advisable to use the nasal tube for this purpose. The 
temperature, pulse and respirations should be the subject of constant and 
frequent observation. Slowing of the pulse and deepening of the respirations, 
when accompanied by headache, drowsiness and increasing unconscious- 
ness, indicate that there is increase in intracranial pressure. A nurse should 
learn to recognize this; in a case such as that under discussion, in which 
lumbar puncture will be frequently performed, careful observation of 
the changes which occur in the patient’s pulse and depth of respiration 
as the pressure is relieved by removal of fluid £rom the theca, should 
demonstrate this effect to her. Icebags are frequently ordered for the 
relief of headache, and it is advisable to get permission to cut the hair 
short. 

The special dangers which are to be avoided in nursing a patient in the 
stage of coma arc pneumonia, which may be brought about by his in- 
haling saliva; hypostatic pneumonia, because he is not turned and moved 
often enough; infection of the bladder, should retention of urine be 



MENINGOCOCCAL MENINGITIS 417 

neglected; bedsores and hot water bottle bums, and infection of the con- 
junctiva when the corneal reflex is abolished, if the eyes are open* 

INFECTIONS OF THE SPINAL CORD 

Myelitis is inflammation of the spinal cord; infantile paralysis^ which is 
described on p. 410, being an example as it is definitely a disease of the 
lower motor neurones. The object of this note, however, is to describe the 
condition known as acute transverse myelitis. 

Acute transverse myelitis is an acute inflammation of a complete 
section of the spinal cord; it is thought to be an infective condition, and 
may follow acute nephritis and influenza, but in many cases it cannot 
be attributed definitely to any known cause. 

The onset may be very sudden; there may be a slight rise of temperature 
accompanied by malaise, when the patient notices he has lost the use of 
his legs and may be unable to pass urine, retention having occurred. 

The first effect of the inflammatory lesion is to produce softening of the 
cord, with the result that spinal shock is manifest; and there is total flaccid 
paralysis below the level of the lesion. If examined, the reflexes will be 
missing and sensation will be impaired; retention of urine is present. 

This condition persists for a few days — ten or more — and the impaired 
sensation gradually improves and the tendon reflexes return. Eventually 
the character of the paralysis is that of an upper motor neurone lesion, as 
occurs in pressure on the spinal cord, spastic paralysis is present, the 
tendon reflexes arc exaggerated and the extensor plantar response 
(Babinski’s sign) is obtained. 

The nursing care is as described in the case of fracture of the spine. In 
transverse myelitis the recovery made may be partial or complete, and it 
depends to a great extent upon good nursing. The use of a water bed is 
essential. The skin must be carefully tended — the patient should never 
be moved by one nurse, and he may not be rolled over but must be lifted, 
while great care is necessary to prevent injury to the skin of the back 
when using the bedpan. Hot water bottles should be carefully guarded as, 
owing to diminished sensation, burns occur very easily. The helplessly 

P aralysed patient is unable to move away from the vicinity of a hot water 
ottlc or any other source of possible injury. 

Catheterization will be necessary for the relief of retention and the danger 
of bladder infection must ever be remembered. It is unlikely that a nurse 
will, even inadvertendy, fail to use proper precautions regarding the 
aseptic technique of passing a catheter, but since the bladder is not able 
to empty itself, owing to the absence of the normal reflex, infection may 
occur. Part of the nursing care which will help to prevent this is the ad- 
ministration of bland fluids in large quantities which act as a mild urinary 
antiseptic. Some urinary antiseptic may be ordered by the physician. 

The prevention of deformity, especially footdrop, is important; a light 
rectangular footsplint is suitable for this purpose, and the bedclothes 
should not be drawn tightly over the feet. The use of mackintoshes may be 
considered necessary in order to prevent soiling of the mattress; but in a 
patient with retention this is unl^ely and mackintoshes are very unsuit- 
aMe for use in the beds of paralysed patients — ^however carefully attended 
to, they tend to collect moisture, which is a potent cause of bedsore. When 



41 8 THE NERVOUS SYSTEM 

a mackintosh is employed, the precaution should be taken of covering 
it with a blanket, ]^aced between it and the bottom sheet, which wiU 
absorb moisture. 


ENCEPHALITIS LETHARGIGA 

Encephalitis lethargica is an infectious disease affectii^ the brain and 
in some cases the spinal cord. It is often associated with epidemics of 
influenza and may occur in epidemic form; sporadic cases are invariably 
present in this coimtry and each case is notified to the Medical Officer 
of Health. 

Infection is considered to be carried in the nasal mucous membrane, and 
it is due to a virus, the incubation period not being known. 

The onset of the disease varies from a rapid, sudden onset in acute 
cases, which often terminate fatally in a week or two, to a slow onset of a 
subacute type in which either lethargica, diplopia, headache, restlessness 
and delirium or persistent hiccup may be the only symptoms present. 

The symptoms present in the course of the disease are as variable 
as those of the onset. When lethargy is present the patient lies inert, un- 
heeding anything which is passing around him, and passes his urine and 
faeces in the bed. This state may last for some weeks and then the 
patient may slowly recover or he may develop Parkinsonism. 

It is generally considered that the more acute the onset the graver is the 
prognosis and, conversely, that the slower the onset and the fewer the 
symptoms the more likely is the patient to recover completely. Many cases 
of encephalitis lethargica who recover are found to have a complete 
change of character, mischievous lads may develop quite saintly characters, 
though, conversely, previously well-behaved children sometimes develop 
habits of lying, stealing and teasing. Adults frequently become unable to 
sustain effort and find themselves unable to concentrate and persevere 
in their former employments, and become careless and slovenly in habit. 

Other mental symptoms include restlessness, delirium and mania; 
the patient is unusually wakeful at night and in many cases is quite insane. 
Even mild cases often develop a reversed sleep rhythm, and the mis- 
chievous boys wake at night and prowl about annoying other persons in 
the same ward, or in the same house or street. 

In a case with an acute onset there is a rise in temperature, the mouth 
is dry and the tongue furred, incontinence of urine and faeces is present. 

Parkinsonism is the name used to describe a group of symptoms — ^the 
common sequelae of encephalitis lethargica — which arc frequently seen 
in adults, but rarely occur in children. 

The attitude the patient adopts is of flexion of the trunk with stooping 
shoulders and head projecting forwards; his elbows are held to the sides of 
his body and his fingers are constantly employed in performing rhythmical 
movements. When he walks he progresses by short mitM:ing steps and takes 
little runs forward and sometimes backward; the knees are sightly bent, 
and the general attitude as described makes the patient look much older 
than he really is. 

The face is characteristically masklOce and remains exprestionless; the 
speech is monotonous and sl^ and the patient fiequently repeats lus 
words. In severe cases salivation is troublesome. 



ENCEPHALITIS LETHAROICA 4I9 

Nursing and treatment. Very litde is known about the treatment of 
this disease, though in some cases intravenous infusion of a solution of 
collosol iodine or of sodium salicylate has been found of value. It is usual 
to relieve intracranial pressure by lumbar puncture when necessary; apart 
from these measures treatment aims at relief of the symptoms, 

tVM regard to the nursing care more can be said. It the patient is acutely 
ill with a high fever, dirty mouth and incontinence, the same careful 
nursing as described in the care of cases of cerebrospinal fever cases on 
p. 416 will be required. 

When lethargica is present the patient should be moved frequently in 
order to prevent hypostatic pneumonia; he should be roused to take 
sufficient fluid. Feeding may be difficult, as keeping the patient roused 
long enough to swallow is often a problem; moreover, he may have 
difficulty in swallowing and in mastication, and may persistently refuse 
even to attempt to take either food or drink. In such cases he may have 
to be fed by means of a nasal tube or by rectum. 

The prevention of bedsores is important; the patient should have sanitary 
attention at regular intervals and if possible be persuaded to use the vessels 
supplied at these intervals; if he will not, he should be cleaned as soon as 
his bed is soiled and should always be provided with pads of wool and tow 
under him so that faeces can be absorbed, and he should have a urinzil in 
the bed, so that bedwetting is avoided. 

The bladder must be observed lest retention of urine should occm, and 
the bowels kept acting regularly by the use of aperients or encmata if 
necessary. 

When the patient begins to recover he should be given interesting occu- 
pations and encouraged to take an interest in everything going on around 
him; the nurse should watch carefully for alteration in character and do 
her best to train the patient in good habits—in eating, cleanliness and 
dressing for example. He should be taught to take an interest in his 
personal appearance and in his accomplishments. It is important to 
remember that if the patient’s behaviour is ill favoured, he probably 
regrets this as much as the nurse, but the tendency to be tiresome may be 
so pressing and his will so weak that he needs all the help she can give him 
and she should never let him see that she is annoyed, but should make 
him understand how pleased she is when his behaviour is kind and 
courteous. 

Children should never be punished, but they must be carefully per- 
suaded, rewarded when they have tried and succeeded, and merely 
allowed to realize that they arc not interesting to othei's when their be- 
haviour is abnormal. 

FUNCTIONAL NERVOUS DISORDERS 

Functional nervous disorders are those in which no organic lesion is 
present, such as major epilepsy^ neuralgia^ hysteria^ paralysis agitans, chorea^ 
and a large number of conditions which arc described as neurasthenia. 

Neuralgia is pain in a nerve, and it may either be due to a number of 
causes — including local pressure, inflammation, toxaemia — or be a mani- 
festation of debility or anaemia. 

^ Trigeminal neuralgia is a very painful type which occurs in the fifffi 
crani^ nerve and is characterized by acute attacks of agonizing pain 



420 THE NERVOUS SYSTEM 

accompanied by tenderness and swelling of the skin over the course dt the 
nerve. 

The treatment carried out at first is to apply heat to the painful area and 
.slight counterirritation; at the same time the general health should be 
considered and attempts made to improve this and also to discover and 
treat any underlying or contributory cause. In some very persistent 
cases it becomes necessary to inject alcohol into the nerve or to remove 
the ganglion from which it arises. 

HYSTERIA 

Hysteria is a functional nervous condition which produces many varieties 
of symptoms. A h^^terical fit and its treatment are described on p. 429. 

The symptoms manifested by a person with hysteria may be motor, as 
paralysis or spasticity or rigidity; or they may be sensory, as loss of sensation 
or hyperaesthesia. They may show a mental tendency such as melancholia, 
and many other symptoms may be complained of, including headache, 
indigestion and p^pitation. 

The treatment should be in the hands of a good neurologist, but in the 
meantime the nurse must remember that the patient may not be able to 
help himself and that he is ill, though not in body. The attitude the nurse 
ought to adopt is to suggest that the physician will effect a cure, and that 
in the meantime it is necessary to be cheerful and not speak of the symptoms 
but rather try to forget them. If the patient displays emotion he should be 
brought to reason by a sharp command. 

PARALYSIS AGITANS 

Paralysis agitans is also described as Parkinson’s disease, because Dr. 
Parkinson first described it. The characteristic symptoms which arc 
recorded here are also seen in the chronic stage of encephalitis lethargica, 
when they are known as Parkinsonism or Parkinson’s syndrome — a 
syndrome being a collection of symptoms which manifest some charac- 
teristic features. 

Symptoms. Paralysis agitans is characterized by tremors and loss of 
power in the muscles, and for this reason it is sometimes called ‘shaking 
palsy’. The tremors tend to cease as the patient attempts to perform any 
action. The arms are held close to the sides of the body and the thumb 
and fingers of both hands are constantly moving as if rolling a pill between 
them. The body is slightly bent, and the head is poking forward between 
stooping shoulders; the patient takes mincing steps and little runs as he 
progresses in walking. The face is expressionless, the skin smooth and free 
from wrinkles, and the speech is slow and deliberate. 

Treatment aims at relief of the symptoms, and attempts arc made 
to re-educate the patient in the performance of his movements. He should 
not be kept in bed, but rather encouraged to do as much as possible fisr 
himself; as all his movements are slow and deliberate, he may take several 
hours to get up and dress himself, even with help, but he should be allowed 
to do so. Massage is employed to keep the muscles of the body in tone, 
and the patient should be taught to perform active exercises under direc- 
tion. The disease is progressive, but a cheerful companion can do much to 



PARALYSIS AOITANS 42 I 

make the patient's last years more interesting. When eventually the patient 
is confined to bed, very careful attention is necessary in order to prevent 
bedsores. 


CHOREA 

Chorea, or St. Vitus’s dance, is described in this section of the work 
because the manifestations of it are largely nervous in character. It is, 
however, a disease associated with rheumatism and tonsillitis and is 
frequently complicated by a heart affection which likewise is due to the 
infection which provided the underlying cause of the condition. It is met 
with in children and young adolescents, more often in girls than in boys, 
and it may occur during pregnancy. An attack of chorea may last for a 
month or two. 

The manifestations of the disease begin gradually; at first the child 
is noticed to be fidgety and nervous, he drops things and cries easily; as 
time goes on he becomes subject to constant involuntary movements, 
jerky in character and quite purposeless. In slight cases the involuntary 
movements cease during sleep; in severe cases they disturb the patient’s 
rest and sleep very seriously. 

The mental aspect of the child is altered; he is emotional, subject to out- 
bursts of crying and of temper; speech is often difficult, being hesitant and 
jerky, and as he is very conscious of this he often refuses to attempt to 
speak. 

Feeding becomes a great difficulty in severe cases as the child cannot 
masticate; he bolts his food when it is retained in his mouth at all, but it is 
so often lost in transit from plate to mouth that marked emaciation occurs. 
The constant movements of the child’s limbs, head and trunk, cause 
injuries to the skin from the bedclothes and bedsores occur easily. 

Chorea may be complicated by endocarditis and pericarditis, and it is 
this danger which has to be avoided if possible; its association with 
rheumatism and tonsillitis must not be forgotten, mania may occur in 
severe cases, hyperpyrexia is also a complication to be feared, and relapses 
are common in children who have had one attack. 

Treatment and nursing. Rest is ordered in the treatment of chorea, 
and it is the business of the nurse to see that this is applied as thoroughly 
as possible, having ever in her mind the danger that heart disease may 
occur, with probable consequent disablement for life. The dmgs employed 
will be sedatives and salicylates, the latter being specific in the treatment 
of rheumatism. 

In severe cases, when the movements arc violent and constant, it may 
be necessary to nurse the patient on the floor, in a pen made of mattresses 
so that he cannot either fall out of bed, or hurt himself as he is thrown 
about the bed by the violence of the movements over which he has no 
control; or a padded bed with sides may be used. The patient's clothing 
should consist of light warm woollens of a shape that will not be easily 
removed; a sleeping suit and bcdsocks might be used; the buttons should 
be removed as the patient will only pull them off, and the suit should be 
fastened by stitches, the bedsocks being sewn to the legs of the sleeping 
suit. The bedclothes should include a blanket placed next the patient, 
and a low pillow is given as it is desirable t6 keep the patient lying as flat 
as possible in order to avoid strain on the heart. 



422 THE NERVOUS SYSTEM 

The mouth should be cleaned regularly and drinks of water given 
between feedings and, as there is danger lest a patient with chorea should 
not receive enough fluid, a record should be kept of the amount given and, 
since he will be able to take only a little at a time, a drink should be 
repeated often. The diet should be light, carbohydrates being mainly 
employed, but it should be sufliicient to avoid wasting. In feeding a child 
with chorea great patience is neceiisary; his head will be constantly mov- 
ing, and he ^ould be given small mouthfuls of food at a time which has 
been well broken up or minced; if a metal spoon is used, it should be one 
with a very blunt edge — though a wooden spoon would be preferable — 
and a fork ought not to be employed for fear of injuring the mouth. A 
wooden or blunt metal cup should be used for drinking, as the patient 
may break a china one with his teeth. He should be fed slowly and given 
drinks at intervals during the feeding; any sensation of choking must be 
avoided as this tends to raise the blood pressure, and is an effort for the 
patient which causes strziin on the heart. 

The skin should be washed once or twice a day, and the nurse must 
decide whether warm or hot water is less irritating or more soothing for 
this purpose, and then use what she finds by experience to be best in 
each case. The routine measures for the prevention of bedsores will need 
to be frequently employed; if parts of the body seem to be predisposed to 
soreness, from either pressure or fidetion, these parts should be protected 
by applying ring wool pads to them, or by their being wrapped in cotton 
wool. 

The patient should be placed on a bedpan regularly as he will usually 
pass urine and stool when this is done and soiling of the bed will thus be 
avoided. The amount of urine should be measured and compared with 
the amount of fluid taken, and it should be tested daily for the presence of 
albumin. The bowels must be kept regularly acting, since constipation 
should never be allowed to occur. 

Sleep is often disturbed by the involuntary movements; this should be 
noted as the physician, knowing rest to be essential, will order some form 
of sedative drug for the control of the movements and to secure for the 
child sleep that is less disturbed. 

The temperature, pulse and respiration rate should be taken and 
charted every four hours; the pulse should be taken oftener in severe 
cases, and any change reported. 

As the disease begins to abate a child patient will need some amuse- 
ment, and this should be carefully chosen; he might have a soft toy to play 
with, but for her own sake the nurse will take the precaution of t^ng 
this to his bed, as otherwise she will be required to pick it up from the 
floor even very much oftener than she will for most children. Voluntary 
movement must not be permitted for some time, because of the tendency 
to disease of the heart, and the nurse must be prepared to sit by the bed 
of the child, constantly but quietly amusing him in very gentle ways. She 
ought also to use the opportunity for teaching him to speak slowly and 
distinedy, but she must not tire or bore him; his litdc efiforts should be 
encomaged and repeated at intervals and failure should never be laughed 
at. When he is allowed to use his hands, placing litde articles in de^ite 
positions, such as is involved in a game on a board, may be useful in 
training him to oo-ordinate the finer movements performed by the hands. 

When the child gets up, he may only be allowed out of bed for a few 



CHOREA 423 

moments at first, and the process of getting him up should be slowly and 
deliberately carried out; when he first walks, a little game might be made 
of this, the nurse making him place his feet near hers as when teaching an 
infant to walk for the first time. He should not be allowed to feed himself 
until he is getting up, and then his movements must be guided for some 
time, as cither he will develop the habit of bolting his food or he will not 
get enough. 


ANOREXIA NERVOSA 

Anorexia Nervosa is a functional disorder in which loss of appetite is 
manifested, the patient being very wasted and having lost all desire for 
food. The patient is often a young woman and it is very sad to sec her 
playing with food and taking an hour or more to eat one piece of thin 
bread and butter. 


PSYCHOSIS AND NEUROSIS 

Since the passing of the Lunacy Act of 1930, fewer cases of insanity are 
certified and therefore many insane and borderline cases of mental disease 
may come into the hands of the general trained nurse, particularly in 
private practice. Many of these cases will be neuroses, some will be psy- 
choses and a few possibly dementia, either dementia praecox or senile 
dementia. 

Gases of psychoses may have delusions and hallucinations. 

Manic depressive psychoses arc most commonly met. These cases 
are depressed and cannot concentrate; this state may pass off and they 
will be normal for a time, then they may become excitable and talkative, 
rushing from one subject to another and then becoming destructive and 
breaking things up. At this period they will be overwhelmed by a sense of 
their unworthiness, and will lose appetite and weight; they are restless 
and anxious and cannot sleep, and as they are convinced they will never 
get better, and may commit suicide, they cannot be left alone. They will 
usually recover in from 2 to 6 months. 

When the patient becomes noisy and destructive the nurse must not let 
liim think she is afraid, and she should not argue with him but agree, if 
this is possible. As soon as she goes off duty the nurse should go over in her 
mind the behaviour of her patient, and make notes of anything like a 
delusion and in doing this she should write down the patient’s exact words. 

Schizophrenia {dementia praecox) occurs in young persons, from 15 
to 30. It is characterized by hallucinations and delusions; the subjects of 
this condition arc incapable of rational thought, and become so apathetic 
that they will neither eat nor speak. For years schizophrenia has been 
considered hopeless, but recently two physicians have established treat- 
ment by cardiazol and insulin respectively. When cardiazol is used large 
doses are given to cause epileptiform convulsions; in treatment by insulin 
coma is produced. In both cases the patient requires observation and care 
to treat emergencies which may arise. 

Senile dementia usually occurs in persons over 50 years of age, and it 
is sometimes associated with arteriosclerosis. In these cases the patient’s 
memory begins to fail, and he becomes suspicious of friends and relatives 
whom he formerly trusted, imagining that they are talking adversely 



424 THE NERVOUS SYSTEM 

about him. He gets wcMried about his money problems and thinks he is 
bccx)ming poverty-stricken and broods over this. 

As the disease advances cases of dementia lose all interest in their per- 
sonal appearance and become dirty in their habits. 

In the treatment and care of them it is necessary to try and get them 
interested and to keep them as cheerful and happy as possible. 


NEUROSES 

A neurosis is a manifestation of symptoms without the foundation of any 
organic disease, and neuroses occur in persons who arc unable, for one 
reason or another, to adapt themselves to the conditions which they meet 
in life. 

The typical picture of such a patient is one who is always worrying about 
some problem; he is anxious and sleeps badly, is unable to concentrate 
and is quite certain that he is suffering from some serious organic disease. 
He may present all kinds of symptoms, including palpitation, indigestion, 
constipation and even colitis, rapid action of the heart, headache, aches 
and pains of all descriptions, sweating, especially of the palms of the hands, 
his hands may tremble when performing movements, and if asked to put 
out his tongue this is tremulous. He gets thin and looks very anxious and 
worried. 

Such a patient will go from one doctor to another until he may meet 
one who may tell him something which pleases, such as the fact that his 
heart may be overacting a little; the patient is pleased and broods on this 
and imagines himself a very ill person indeed and his state of neurasthenia 
goes from bad to worse. 

In the treatment and nursing care of a patient suffering from any neurosb 
the nurse must remember that, although not organically ill, the patient is 
ill, and requires just as much care as a serious case of heart disease, though 
in a different way. The physician does not tell the patient there is nothing 
the matter; he listens most sympathetically, talks over the patient’s 
symptoms with him and tries to show him how they have arisen and in 
what ways they can best be dealt with in order to effect a cure. Such 
patients are very anxious to help themselves, they will receive suggestion 
willingly and can be encouraged to do as the physician suggests. 


SPECIAL POINTS IN THE NURSING OF NEUROLOGICAL 

CASES 

In the nursing of neurological cases certain points have to be considered. 
Some neurotic symptoms are associated with all organic lesions and 
allowance must be made for this; it is probably due to the fact that the 
disease from which the patient is suffering and the mode of life he is 
forced to live because of it, is undermining the mental resistance of the 
patient as well as his vitality. 

Again, a neurosis may be present in conjunction with some organic 
disease; or the neurosis may be the only condiition present. 

Neuroses may be present in hysterical form, as an anxiety state or as an 
obsessional condition. The symptoms which arc manifested depend usually 
for their existence on some emotional conflict; the patient is not aware, 
nor does he want to be, that this conflict exists. 



NURSING OF NEUROLOGICAL CASES 425 

All illness has a mental aspect, no sick person can be considered normal; 
in the nursing of neuroses the mental symptoms will be most obvious; in 
the care of a patient who has sustained a fracture, the condition may 
appear to be entirely physical; but, as people consist of both mental and 
physical parts, one part cannot be disorganized or diseased without the 
other’s being affectw. There is no subjective symptom which cannot be 
produced by the mind; conversely the mind can act upon every symptom 
and effect some relief. 

The nursing of neurological cases does not differ from other 
branches of nursing in that the highest qualities of mind and body are 
required in a nurse. The mental aspect of the care of a patient is of very 
great importance in cases of disease or disorder of the nervous system. 
This depends on the ability of the nurse to get into contact with the mind 
of another, and to do this she must be interested enough to learn facts 
about the patient, his ordinary life and surroundings. She Avill gain in- 
fluence over her patient only in so far as she realizes that the relationship 
between them is that of one human being to another. 

It would be ideal if every nurse in training could attend a number of 
lectures on elementary medical psychology and that this should be fol- 
lowed up by clinical instruction on the mental symptoms manifest in 
patients in a medical ward. This should be carried out and supervised by 
a mentally qualified practitioner or trained mental nurse. 

In handling neurological cases it is wise to develop a quiet confident 
attitude; a nurse should be transparently honest with her patients, answer 
their questions with directness, and never tell a patient a lie. The nurse 
who can forget herself and think first of her patient is invaluable; her 
generosity will react on his behaviour, and help him to recovery more than 
could anything else. There need not be any display of sentiment, and the 
nurse must never abandon her authority, but this attitude will inspire 
the patient with the trust, confidence and hope he needs. 

If the patient wishes to talk about his symptoms it is advisable to allow 
him to do so, but only in so far as it will help. A nurse should learn to be a 
good listener; she will be, if she is really anxious to help. As the patient 
relates his symptoms the nurse must remember that a number of causes 
may be contributory, and that if she can discover a possible cause, and get 
her patient to see this also, she may help in his cure. 

Palpitation, rapid action of the heart and headache, may all be due 
(for example) either to anaemia, fatigue or irritability. If the patient has 
attacks of palpitation (for instance) the nurse should try and notice what 
conditions precede the attack; if she can discover that it was provoked by 
irritability she might try and get the patient to see this; she may have to 
set to work in a very roundabout way to reach the end she has in view, 
explaining to the patient how the mind reacts on the body, showing how 
fear will make the pulse beat more rapidly, that hurrying up a hill might 
have the same effect, and so eventually bring him to be interested in 
finding the possible cause of his own attack — ^in this case, of palpitation — 
and so try and get him to avoid the display of irritability which may 
have been a contributory cause. 

In many cases a patient will be pleased and will be found willing to help 
by trying to find tne causes for and to cure his own condition. 

On the other hand, some patients will think they know better, and will 



4s6 the nervous system 

always find some reason for not doing what the nurse may requircj it is a 
good plan to try and strike a bat^gain with such a patient as this and, 
giving in to him in small matters such as the way in which his bed is made 
or his lunch tray arranged, getting him in exchange to carry out the wishes 
of the physician in regard perhaps to what he is to eat or drink, the time 
he is to take medicine, the horn: at which he is to retire, and other similar 
details which are far more imp>ortant than those in which he is being 
allowed to please himself. 

Other patients always want to please themselves, finding it difficult to 
defer to a nurse, and it is advisable in dealing with a patient of this type to 
refer all the important points to the physician in the presence of the patient, 
so that, when the time comes for any treatment to be suggested, the patient 
knows the doctor said exactly this or that and will submit more readily. 

The nurse may find the patient’s relatives difficult, but she must treat 
them also in a quiet confident manner, hoping that they may follow her 
example, so that when in the sickroom they may avoid giving the patient 
any bits of bad news, telling him any distressing tales, moving about in a 
way which will irritate him, speaking in loud tones, and so on. 


FITS AND CONVULSIONS, AND COMA 

ConTulsions in infants are likely to occur whenever the nervous 
system is either directly or indirectly irritated. In infants and young chil- 
dren convulsions occur during teething as the result of gastro-intestinal 
disorder, particularly constipation; owing to the presence of intestinal 
parasites; because the infant is debilitated, particularly when the calcium 
content of the blood is abnormally low — it is because of this, that convul- 
sions arc sometimes seen in cases of rickets. They also occur as the result of 
irritation from the circulation of toxins of disease in the blood; they arc 
met at the onset of many diseases such as measles, scarlet fever, broncho- 
pneumonia and meningitis; they may occur during the course of these 
diseases, particularly the two last mentioned; they may occur at the end 
of a severe attack of coughing, in whooping cough; they are also seen in 
uraemia, in any condition where asphyxia is present and will frequently 
be seen when an infant is dangerously ill and very near death. Convul- 
sions also occur in infants as a symptom of disease of the brain, such as 
cerebral haemorrhage. Sometimes convtilsions occur in infancy and no 
apparent reason can be discovered, and in piany instances these children 
will be found to develop epilepsy in later life. 

A typical fit. The infant becomes rigid and pale, twitches slightly and 
his eyes become fixed. After a moment or two pallor gives way to cyanosis, 
and the infant loses consciousness. This usua% lasts for a few moments, 
and then he regains consciousness, but is Mt weak and falls into a 
stuporous sleep. 

The immediate treatment is to loosen all clothing, see that breathing is not 
obstructed and hold the infant’s head over to one side; if the teeth are 
erupted and there is any tendency to bite the tongue, a pad of material or a 
spatula should be held between them. In the case of a prolonged convulsion the 
infant should be undressed and held in a bath of hot water — from ioo° 
to 103° F. If available, an ounce of mustard may be added to 5 gaUems of 
water; the chest should not be submerged and a cold water compress may 
be applied to the head. 



FITS AND CONVULSIONS 487 

The nurse should observe the duration of the fit and the manner of its 
starting, and note which muscles twitched and in what order, whether the 
pupils were dilated, and whether the eyes remained fixed or squinting, or 
moved in any way. She should abo note whether consciousness was com- 
pletely lost, and for how long the condition continued, and whether the 
infant passed urine and flatus or faeces. 

Subsequent treatment. The occurrence of a fit will be reported to the 
physician who will try to discover its cause; if constipation is preserxt an 
enema will usually be given, followed by a dose of grey powder or castor 
oil; if cerebral irritation is suspected a s^ative may be ordered, such as a 
small dose of bromide, which may be given rectally or by mouth. 

Fits or convulsions in adults may arise from a number of causes, fairly 
common ones being uraemia, epilepsy, apoplexy, cerebral tumours, and 
other organic disease of the brain; they may also arise in cases of tetany, 
when the calcium balance of the body is disturbed; they occur in tetanus, 
and may be met as a complication of pregnancy in eclampsia. An hysteri- 
cal fit may also arise as a manifestation of functional nervous derangement. 


EPILEPSY 

Epilepsy may be of various types, major, minor and Jacksonian epilepsy 
being described. 

In major epilepsy the actual fit is commonly preceded by a warning 
or aura, which takes the form of some sensation, as of discomfort or a smell 
or taste. 

The next stage is described as tonic, and in this the patient falls, is stiff 
and rigid, his eyes are fixed, his teeth and hands are clenched, the muscles 
of his chest are not moving, and he becomes deeply cyanosed. This lasts 
for about half a minute, but to the onlooker the time seems interminable. 
The patient then relaxes, and passes into the next stage of the fit. 

The clonic stage is characterized by convulsive movements, the limbs jerk 
and the tongue may be bitten in the convulsive muscular movements of 
the jaws. Urine and faeces may be passed involuntarily. 

The patient will now probably come round, but he is dazed and scarcely 
recognizes his surroundings; he is tired and weary and will usually fall 
asleep and when he wakens he may not even know that he has had a fit. 

Care of a patient in a fit. The clothing should be loosened about the neck 
and chest; note should be taken that the breathing is not obstructed, if the 
tongue tends to fall back it should be pulled forward, either by taking 
hold of it with a clean handkerchief or with tongue forceps if these are 
available. All nurses should be clearly instructed that a patient will not 
die whilst he is having a fit, provided a clear airway is maintained and he 
is not allowed to turn over on to his face and suffocate. Knowing this a 
nurse will be able to act promptly, calmly and with confidence; further, 
she should be told that, having seen to the point just mentioned, her mwt 
important duty is to observe exactly what happens during the fit and write 
this down at once; otherwise in half an hour’s time she will not be sure 
whetiber the movements began on the right or on the left side. 

The patient should lie where he has fallen, provided he is not in danger, 
and any firm article such as a rubber ring or a spatula should be held 
between his teeth to prevent his biting his tongue during the convulsive 



42B the nervous system 

movements of his jaws. If, however, the patient is in bed, he should be 
prevented from failing out. 

The following points should be noted: The mode of onset of the fit, whether 
sudden or gradual; whether it began with a scream; the character of the 
movements, whether tonic, or clonic; the part of the body where move- 
ments began, and the exact order of spread and whctlicr the tongue was 
bitten. The colour of the patient, as to whether his face was flushed or pale, 
and the condition of his pupils, whether dilated or not. The presence or 
absence of the comeal reflex, the condition of the pulse during the attack, 
and whether the patient passed urine or faeces involuntarily. The dura- 
tion of the attack should be noted and any symptoms which followed 
observed, such as headache, drowsiness or vomiting, whether the patient 
immediately went to sleep or whether, alternatively, he performed move- 
ments automatically (see note on automatism below). 

Dangers of epilepsy. There is always danger that the patient will be in- 
jured during a fit, as he may fall in a dangerous place, under a moving 
vehicle, from a height, into water or on to a fire, and it is for this reason 
that persons who are subject to epilepsy should not follow dangerous 
occupations, such as working on a high building, in a factory where 
machinery is used or driving a vehicle. 

Status epiUpticus is a condition associated with epilepsy in which fits 
follow one another in rapid succession. The treatment is medical and the 
physician will as a rule order an enema to be given. He may order sedative 
drugs such as luminal, paraldehyde, potassium bromide and chloral 
hydrate. 

The physician will expect the nurse to obtain a specimen of urine and 
test it for albumin as soon as possible, as repeated epileptiform seizures 
may be caused by uraemia and an early diagnosis is important. The pulse 
and the character of the tongue should be observed in elderly persons, 
the pulse may be found to be tortuous, full and bounding, or slow; in 
some cases of severe heart block seizures very similar to epilepsy sometimes 
occur. Stimulants should never be given in status epilepticus. 

Automatism is a condition in which a patient performs movements and 
carries out, in some cases, very complicated performances, without having 
the least idea of what he is doing or any memory of it afterwards. A patient 
in this state is not responsible for his actions, even should he commit 
violent injuries to other members of society. He needs careful watching 
and should not be left alone, even for a moment. 

The mode of life and general care necessary in cases of epilep^. An epileptic 
should lead a quiet, fairly uneventful life; he should sleep well and, if 
unable to do this naturally, the physician may order small regular doses 
of some sedative drug — ^luminal ^ to J of a grain is commonly given twice 
a day or one dose of i J grains may be ordered to prevent an attack. More 
recently epauntin or alepsin has been employed to prevent fits or lessen the 
frequency and severity of them. The diet should be nourishing but not 
stimulating, and the bowels should be kept acting regularly. If the patient 
has any idea when a fit is likely to occur he should regulate his life in 
OTder to try and avoid having a fit. 

Petltmal, or minor epilepsy, is a form in which only very slight attacks 
occur, but this form of the disease unfortunately tends to become worse 
as time goes on and is difficult to treat. 



EPILEPSY 429 

In an attact of petit mal there may be a slight momentary lapse of con- 
sciousness; should it occur in a nurse she might be seen to stand rigidly 
still for a moment or two, perhaps when making a bed, and then continue 
the work as if nothing had happened; she might be making a report and 
suddenly stop speaking, continuing after the lapse of a few moments; if 
she was holding something she would probably drop it. The colour of a 
person having an attack of petit mal may change, and he may become 
pale with fixed staring eyes during the momentary lapse of consciousness. 

The treatment in the first instance consists in trying to discover any cause, 
and then in keeping the patient on some sedative drug; either bromide or 
luminal in small doses several times a day is frequently employed for this 
purpose. A fairly long rest from occupation should be advised at the 
beginning, and it is very obvious that if the subject is a nurse she will not 
be able to follow her occupation, as during even a short lapse of conscious- 
ness she might be the cause of serious injury to a patient. 

The prognosis of petit mal varies; some patients tend to recover, others 
do not; some develop major epilepsy and many of those who do not 
recover become subjects of automatism following an attack, are difficult 
to handle and behave in a dangerous manner. 

Jacksonian epilepsy is considered to be associated with some organic 
lesion of the brain, whereas the types of epilepsy already described are of a 
functional nature. One cause of Jacksonian epilepsy is a cerebral tumour, 
and it is therefore most particularly necessary in this type to make accurate 
observations of the happenings during a fit, since what the nurse can tell 
the physician or surgeon about this will go far in helping him to decide 
the exact localization of a tumour. In attacks of Jacksonian epilepsy con- 
sciousness may not be lost. 


HYSTERICAL FIT 

A nurse should be familiar with the differences between the condition 
of a patient in a true epileptic fit and that of one in an hysterical fit. The 
main points may be outlined as follows : 

( 1 ) An hysterical fit never occurs when a patient is alone or during sleep. 

f 2) The order of events described in epilepsy does not occur in hysteria. 
3) The movements which are made during an hysterical fit are not 
involuntary; they are wild and spectacular in character and if attempts 
arc made to restrain the movements their violence is increased. 

(4) The patient docs not hurt himself in falling, and he does not bite his 
tongue. 

(5) Incontinence of urine is not present — unless the patient happens to 
know a great deal about epilepsy, in which case he may pass urine during 
the attack, wishing to complete the picture he desires to convey. 

(6) The corneal reflex, which is lost during the clonic stage of , true 
epilepsy, is present in an hysterical attack. 

The treatment of a patient in an hysterical fit is to give a sharp command to be 
still, and then to ignore the attack. One point, however, must be con- 
sidered: an hysterical fit may follow an attack of petit mal, so that the 
history should be investigated when the patient is behaving normally 
again. 



430 


THE NERVOUS SYSTEM 


APOPLEXY 

Apoplexy is the term used to describe a seizure characterized by sudden 
loss of consciousness, accompanied by noisy stertorous breathing, flushing 
of the face, a full bounding pulse and pandysis of one side of the body 
(see also hemiplegia). 

Apoplexy is due to cerebral haemorrhage in most cases, although in 
other instances it may be brought about by cerebral thrombosis or cerebral 
embolism. 

The symptoms of onset may occur suddenly as instances above; or the 
condition may come on gradually. When the cause is thrombosis — that is, 
a blockage of one of the blood vessels — ^the onset may be gradual, as the 
clot gradually forms in the vessel. In such a case the onset of paralysis may 
precede the other symptoms; later, as the blood vessel becomes completely 
blocked, the typical pictme of a patient in a state of apoplexy will be seen. 

The immediate treatment of a patient who may (for example) have had an 
attack of apoplexy either in the street or at his work is to put him to lie 
down, with his head raised, and the clothing about his neck and chest 
loosened; his head should be placed to one side and means taken to see 
that his breathing is not obstructed. A cold application should be placed 
on his head and he may have a hot water bottle at his feet; he should not 
be given any stimulant and a doctor should be informed at once. 

The subsequent nursing will be that described for a case of hemiplegia 
on p. 408. 

(Eclampsia. This is a complication of pregnancy in which epileptiform 
seizures occur; it is described on p. 548.) 

COMA 

Coma is a state of deep unconsciousness from which a patient cannot 
be roused. It may be brought about by a number of causes. It has 
been mentioned in connexion with injuries to the skull. It may also arise 
from pressure caiised by a cerebral tumour or abscess; and in cerebral 
haemorrhage, and meningitis. Other causes include toxaemia of disease, 
uraemia, diabetes, poisoning by the abuse of alcohol or hypnotics, and 
sunstroke. 

The most Important observations to be made in the case of coma 
are: 

(1) Any irregularity of the temperature, pulse and respiration; a half- 
hourly note should be made for the first few hours. 

(2) The degree of coma, whether this varies at all, and whether the 
patient is able to swallow, 

(3) Any movements of the limbs; if these occur only on one side, this 
fact should be noted in particular; any movements of the eyes should also 
be noted — if the eyes are being constantly tunwd to one side, it is important 
to know which side. 

(4) The pupils should be observed for irr^ularity in size; the eyes 
should be examined for the presence of die reaction of the pupil to light, 
and also for the presence or absence of the corneal reflex — this is only 
lost when coma is deep. 



COMA 431 

(5) A Specimen of urine should be obtained as soon as possible, and 
tested. The bladder should be watched for distension; any incontinence of 
urine should be noticed. 

(6) Any retraction of the head should be noted. 

Treatment and nursing is similar to that described in the care of a 
fractured base of the skull (see p. 598). Cases of coma should be nursed 
on a water or air bed, and the skin on which the patient lies shoidd be 
attended to every four hours as there is danger of bedsores; the head should 
be kept turned to one side in order to obviate the danger of the tongue’s 
falling back and so obstructing the breathing; the mouth, nose and the 
eyes, when these are open, should receive regular attention and be kept 
clean and healthy. The bowels should be kept open; if the patient does 
not recover from coma within from 36 to 48 hours he will be artificially 
fed by the rectum or by means of a nasal tube. 



Chapter 27 

Diseases and Disordei's of the Endocrine Glands 

Introduction — The thyroid glands cretinism, myxoedema, and Graves's disease — 
The suprarenal glands, Addisons disease — The parathyroids, tetany and von 
Recklinghausen* s disease — The pituitary gland, functions of anterior and posterior 
lobes, Simmonds's disease — The ovarian and iestical secretions — The intrinsic 
factor of Castle — The pancreas, diabetes 

T he importance of the endocrine system, its association with the 
central nervous system, and the necessity for the perfect regulation 
of the mechanism by which the chemical messengers or hormones 
are sent out from the endocrine glands to the blood stream, to exert their 
action on the physical and mental wellbeing of the body, are the subject 
of great interest and much research today. Many of the organs producing 
internal secretions have a dual function — the pancreas (for example) 
makes an external secretion which it pours into the duodenum, and a 
hormone which it sends into the blood — this is known as insulin, and it 
controls the use of carbohydrates in the body and a deficiency in its supply 
gives rise to diabetes mellitus. 

In the nursing care of patients with disordered endocrine conditions, 
particularly pemaps in disorders of the thyroid and pituitary glands, the 
nurse is faced with difficulties very similar to those with which she meets 
in the care of neurological cases, for it is the disturbance of the emotions, 
so common in such patients, that gives rise to difficulty. 

DISORDERS OF THE THYROID GLAND 

The thyroid gland produces the thyroxin which regulates metabolism. 
Lack of this substance — hypothyroidism — causes cretinism in infants and 
myxoedema in adults. 

In cretins the baby is born apparently normal and the symptoms begin 
to develop in from three to six months; the child then becomes lethargic, 
the skin is dry, and the hair brittle; he is constipated, and dentition and 
talking are delayed. He makes no attempt to move, but sits lazily about, 
his abdomen becomes prominent and, if this condition is not treated, he 
will grow up an imbecile cretin with undeveloped sex characteristics. 

M3rxoed6ma arises in adult life — the patient gets fat, the skin and hair 
become dull and dry, the hair falls out, the subcutaneous skin becomes 
thickened, giving the patient a gross bloated appearance, great bags of 
skin lie under the eyes, the mentality is dull, lethargy proceeds to idiocy 
and the patient is inattentive to his surroundings and consequently 
appears to be deaf. Constipation is present. In women amenorrhoea 
occurs. Both myxoedema and cretinism respond to the administration of 
thyroid extract. 

HYPERTHYROIDISM 

Hyperthyroidism is due to overactivity of the gland, which causes it to 
produce an excessive secretion. In some cases the secretion is definitely 



HYPERTHYROIDISM 433 

thought to be abnormal in character,* and it then produces symptoms of 
toxaemia. There are several forms of this condition, but the one which 
most seriously disturbs the patient’s mental balance, and which requires 
infinite tact, patience, observation and thoughtfulness on the part of the 
nurse is Graves's disease, or exophthalmic goitre. In these cases the sympathetic 
system is overactive and a train of emotional symptoms arises, accom- 
panied by a number of other symptoms due to defective control of 
metabolism. 

The symptoms most commonly met with arc protrusion of the eyes, 
tachycardia and other forms of irregularity of the heart; there is usually 
some enlargement of the gland, the skin is moist, the temperature is 
usually raised a little; the patient may have a normal appetite, but owing 
to defective metabolism he loses weight. In many cases diarrhoea is 
present, and insomnia, irritability and general restlessness are all exceed- 
ingly troublesome symptoms. Such patients are in a state of high nervous 
tension, they arc apprehensive and critical, sensitive and introspective, 
and they require to be frequendy reassured and must not be worried or 
frightened. If nursed in a general ward they should be placed in a quiet 
part of it and not in the vicinity of very ill patients, but if possible near to 
happy cheerful ones. 

Treatment and nursing. The patient may be admitted for medical 
treatment or for treatment in a medical ward preparatory to the operation 
of thyroidectomy. The reception of this patient is important, and he should 
be made to feel that he is expected and that his bed is ready for him; in no 
circumstances should he be taken or sent to the bathroom; if he is thought- 
lessly put next to a seriously ill patient he may refuse to remain in hospital 
for treatment. In the majority of cases the patient will be kept in bed, and 
will not be allowed to wash himself. 

The rapid action of the heart is due to toxaemia from the abnormal 
secretion of the overactive gland, and the primary treatment is rest. The 
administration of this rest must be considered in all its phases, both as regards 
physical rest in bed and abo regarding the avoidance of mental excite- 
ment, such as might be brought about by injudicious visitors or the reading 
of unsuitable exciting literature. Observation of the rhythm of the pulse 
b very important, and the physician will usually order some form of 
sedative drug, together with some drug to control the action of the hetut. 
He will abo investigate the presence of any septic focus in the body, and 
may order the adminbtration of Lugol’s solution of iodine. A careful 
record of the basal metabolic rate will be made. The first test b carried 
out very soon after admbsion; the patient b then given graduated doses 
of iodine, and the test is repeated at regular intervals, until the physician 
finds that the basal metabolic rate has reached the lowest point to which 
it can reasonably be expected to fall, and at this point the operation b 
performed. 

The diet is very important, and should be nourishing and easily digesti- 
ble; stimulants should be avoided and red meat given only sparingly. The 
patient may have plenty of fish and eggs, and a little chicken, plenty of 
milk, cream and butter, milk pudding and fruit and green vegetables 
in order to try and overcome the wasting due to toxaemia. The patient 
should be weighed every week and a chart kept, but the nui'se should 
not put too much emphasis on loss, or failure to gain weight, as thb will 





HYPERTHYROIDISM 435 

give the patient something to worry about; but she might gently praise 
and appear pleased by any gain in wei^t. 

During this period of medical treatment the patient may question the 
nurse as to the necessity of an operation, and she should make it her 
business to know what the physician in charge advises and, if he advises 
operation, she should talk quite naturally and simply to the patient about 
the benefits to be obtained. She might say, for example, that patients 
recover very rapidly, that the symptoms disappear quite quickly, and that 
one reassuring feature is that, because the gland has been removted, there 
is no fear of any return of the condition. She should never tire of reassuring 
these patients, and should not forget the mental strain they are under- 
going, realizing that the patient’s co-operation is very necessary for a good 
recovery, and that she herself can help him to face the immediate future, 
and in so doing ensure a happy, confidently accepted, more remote future, 
looking forward to the time when the patient can again take his place in 
the world, in a fit state to face the difficult problems of Ufe. 

A patient who is to be operated on may be taken direct to the operating 
theatre from a medical unit, or may be transferred to a surgical unit a day 
or two beforehand. In the latter case it is very advisable that he should 
meet patients who have had the same operation and who have done well 
and are happy and contented. The preparation and post-operative 
nursing care are described on p. 663. 


THE SUPRARENAL GLANDS 

The suprarenal glands produce two secretions, one from the medulla, 
which is known as adrenalin, and the other from the cortex — cortin. 

Addison’s disease. In the disease described by Dr. Addison the func- 
tion of the suprarenal glands is disordered and, as there is deficiency of 
adrenal secretion, the disease is therefore characterized by a low blood 
pressure, and the pube is poor and of low volume; the patient is incapable 
of exertion, attacks of fainting occur and he feels the cold severely. There 
is usually marked wasting, and in many cases there is discoloration of the 
skin, the patient is subject to frequent attacks of nausea and vomiting and 
in some cases diarrhoea occurs. 

The disease is progressive, and if untreated the patient becomes very 
anaemic, and gets gradually more emaciated and weaker, until he is 
unable to leave his bed. The disease is characterized by attacks of syncope, 
and may end fatally in an attack. 

Treatment. Quite good effects arc being obtained from the administration 
of cortin, which is an extract of the cortex of the gland. 

THE PARATHYROID GLANDS 

The parathyroid glands produce a substance which has been isolated 
and is called parathormone. It is concerned in maintaining the calcium 
content of the blood, and deficiency or hypoparathyroidism produces many 
conditions including tetany, osteomalacia and severe chilblains. 

Tetany — due to hypoparathyroidism and brought about by deficient^ 
of calcium in the blood may occur in infants and adults. In infants it is 
associated with rickets, laiyngeal spasm and convulsions. It may be 



436 THE ENBOCRINB GLANDS 

associated with meirked diarrhoea and vomiting, with removal of the 
thyroid gland, and occurs as a complication after removal of a parathyroid 
tumour (sec below) and is sometimes seen in pregnant women. 

The oTiset of tetany is manifested by tingling in the limbs and stiffness and 
rigidity. The characteristic carpo-pedd spasms are painful contraction of the 
thumb across the palm of the hand and adduction of the feet and flexion 
of the toes. Convulsions and twitchings may also occur. 

The treatment consists in the administration of calcium daily; in some 
instances parathyroid extract is employed. If the spasms arc frequent 
and distressing, chloroform inhalations may be necessary for iimncdiate 
relief. Sedatives such as bromide and chloral are employed. The provision 
of a diet rich in calcium is necessary and it should therefore include milk, 
eggs and cheese. Constipation must be prevented and the bowels should 
be kept acting regularly. 

Hyperparathyroidism — ^Von Recklinghausen’s disease — is thought to 
be due to tumours of the parathyroid glan^. It is also described as osteitis 
fibrosa. Owing to the excessive activity of the parathyroid glands the 
calcium content of the blood is abnormally high, but the skeleton is 
deprived of calcium, and consequently the bones are brittle and fractures 
occur easily — a bone may be broken by simply turning over in bed — and 
as the result of numerous fractures the skeleton becomes seriously de- 
formed. 

The treatment adopted is removal of the parathyroid glands. Before 
operation the patient is admitted for observation; his diet is regulated, 
and he is given at first a low calcium diet, the intake and output of calcium 
being measmed and the blood calcium content estimated, and the 
skeleton is X-rayed to note the condition of the bones. 

The post-operative care is complicated by anxiety for fear lest tetany should 
develop. The calcium content of the blood falls rapidly once the over- 
acting glands have been removed. 

The nurse must watch for any signs of the development of tetany; she 
may notice that the patient becomes irritable; if he complains of sensa- 
tions as of pins and needles in his limbs she may know that tetany is 
imminent, and these symptoms will soon be followed by spasms. The 
physician will now order the patient to be given calcium gluconate by the 
intramuscular route sufficiently often to prevent attacks of tetany. 


THE PITUITARY GLAND 

The anterior part of the pituitary gland produces a number of 
hormones, and it is now considered that these play a very important part 
in the control of the general wellbeing of the metabolism of the body, 
promoting the regulation of all physical activity, the growth of the body 
and the activity of the sex glands; one of these secretions controls the 
activity of the ovarian hormones, and is thought to play a great part in 
the control of emotions, and to be intimately concerned with the control of 
sleep. Disease or disorder of the pituitary glgnd gives rise to a long train of 
symptoms, many of them affecting the sympathetic nervous system and 
being characterized by emotional disturbance. Other hormones from the 
antericM: lobe of the pituitary gland arc concerned with the control of the 
breasts and the secretion of milk during lactation, and with^^thc control 



THE PITUITARY GLAND 437 

of the activities of the thyroid, adrenal and parathyroid glands (see 
accompanying chart). 

Gigantism and acromegaly arise as the result of hypersecretion of 
the somatotropic hormone, which controls growth. Gigantism occurs when 
the condition is present before growth has ceased. Acromegaly is seen in 
adults, of middle age; it is characterized by enlargement of the lower jaw 
and malar bones, the nose is broad and the skin thick and coarse, the feet 
and hands are large and the fingers spatulate in shape. 

It is thought that this condition is produced by the presence of a pituitary 
tumour, a danger of this being that pressure on the adjacent optic nerves 
may cause loss of sight. The tumour is sometimes removed ; in other in- 
stances the condition is treated by the administration of thyroid extract 
and also by extract of antuitrin. 

Dwarfism is retarded growth due to undersecretion of the somatotropic 
hormone. 

Simmonds’s disease is characterized by cachexia and premature 
senility due to deficiency and loss of all the hormones of the anterior lobe 
of the pituitary gland, as the result of degenerative changes which have 
taken place in it. 

The posterior lobe of the pituitary giand produces a secretion called 
pituitrin. It contains two hormones: vasopressin which raises blood pressure 
and oxytocin which stimulates contraction of the uterus. 

Overproduction of pituitrin causes hyperpiesis of the hypertensive type (see 
p. 357) and underproduction gives rise to diabetes insipidus. 

In diabetes insipidus the balance of water in the body is upset and the 
patient is passing large quantities of pale-coloured urine with a low specific 
gravity of 1,002 or 1,005. As much as several hundred ounces may be 
passed in 24 hours. This marked polyuria is accompanied by thirst and 
constipation, wasting occurs owing to deprivation of the body of fluid 
and, because he is frequently disturbed at night to pass urine, the patient 
becomes tired and weary' from loss of sleep. He is unable to carry on any 
ordinary occupation owing to frequent interruptions. 

In some cases the condition is relieved by pituitrin. 

The ovarian secretion. Two quite distinct hormones arc described: 
one, oestrin or folliculin, is thought to control sex development and the 
activity of the uterus during the menstrual cycle, and a preparation of 
this hormone is employed in the treatment of a number of symptoms 
occurring at the menopause; the second ovarian hormone, prepared in 
the corpus luteum and usually described -as progestin, is thought to be con- 
cerned with the control of the periods of rest of the uterus. 

The testes also produce internal secretions which are thought to control 
sex characteristics in men. 

THE INTRINSIC FACTOR OF CASTLE 

Pernicious anaemia is now known to be associated with lack of the 
intrinsic factor of Castle in the gastric juice, and this also can be looked 
upon as a hormone and in the treatment of pernicious anaemia an extract 
of it is frequently administered in the form of desiccated hog’s stomach. 



438 


THE ENDOCRINE OLANDS 


THE ISLETS OF LANGERHANS IN THE PANGRBAS 

Diabetes is a disease which is now known to be due to deficiency of an 
internal secretion produced by the beta cells of special areas in the pan- 
creas, known as the islets of Langerhans. The secretion produced by these 
cells is called insulin and when it is deficient in quantity, owing to disease 
or disorder of the function of these cells, there is an excess of sugar in the 
blood and sugar is then excreted by the kidney, and by this characteristic 
the condition of diabetes is recognized. 

Little is yet known of the actual causes of diabetes, but certain conditions 
are considered to be contributory, including mental and physical strain 
and worry and anxiety; the presence of septic foci in different parts of the 
body, certain infective diseases such as influenza; diabetes is also some- 
times associated with gout and with obesity when this is brought about by 
overfeeding. 

The symptoms of diabetes are the passing of a lot of urine up to 
several hundred ounces in severe cases — which contains a varying amount 
of sugar (glycosuria). Urine is frequendy passed because of the excessive 
amount and the rate at which it is excreted, and this symptom, polyuria, is 
only nature’s way of dissolving the sugar so that it can be excreted, and is 
an attempt to lessen the abnormally high percentage of sugar in the blood. 
Normally the amount of sugar contained in the blood is about O’l p>er 
cent., but in diabetes it may be as high as 0-5 or o*6 per cent. 

Thirst is another symptom which is due to the serious loss of water 
from the body by the kidneys, and the tongue is characteristically dry, 
red and raw. 

Muscular weakness and loss of weight occur because the sugar cannot be 
used unless insulin is also present in the blood, so that although there is 
excessive sugar in the patient’s blood he cannot be nourished, and there- 
fore loses weight. 

Sugar, which is necessary for the combustion of fat, cannot be stored in 
the muscles, and heat and energy are therefore lacking and the patient is 
weak and listless and very easily fatigued. 

Complications and dangers of diabetes which accompany the 
symptoms in severe cases include itching of the skin, pruritis and eczema, septic 
spots on the skin, and boils, carbuncles, abscesses and coma', the patient is subject 
to any infection, especially bronchitis and pulmonary tuberculosis', diabetic 
cases often get neuritis, which is thought to be due to lack of proper nourish- 
ment for the nerves; and for the same reason they are subject to retinitis and 
cataract. In very severe cases gangreru of the extremities, particularly the 
toes, occurs; and, owing to the excessive sugar in the blood and the con- 
sequent difficulty of he^ng, diabetic patients are considered bad subjects 
for surgical operation. 

Coma. The most serious and immediately fatal danger is of diabetic 
coma, which is due to the presence in the blood not of sugar, but of diacetic 
acid and acetone (acetonaemia), which occurs owing to the defective 
metabolism of fat. 

The symptoms of threatened coma are diacetic acid in the urine, complaint 
of headadhe, and vague abdominal pain; the patient begins to be drowsy, 
his breathing becomes gasping, which demonstrates ‘air htmger’ and there 



»CRINE SYSTEM 


OVERPH 

UNDERi 


8 


OVERPRODUCTION THYROTOXICOSIS 

UNDERPRODUCTION CRETINISM 
MYXOEDBMA 

THYROXIN 


THYROID 


GLAND 


THYROTROPIC HORMONE 



rm 


PANCREATIOOTROPIC HORMONE 


I^ANCKEAS 


CONTRACT* 

TKK 


VNDERPRODULU 


INSULIN 


OVhHPRODVCTION 


S}^)NrANEOUS 

HYPOGLYCAEMIA 


UNDLRPRODUCUUN DIABETES 


^ PARATIIYROTKOPIC HORMONE 

, 

FAKATHYROID GLANDS 

I 

I 

^ i'AKAlHORMONE 

A^R^:^ 


OVERPRODV 


VNDERPROL 

1 

J 


OVERPRODVi llON OSTEITIS FIBROSA CYSTICA 

OK 

\ON KLCKLINC. HAUSEN’S DISEASi: 
LW'DhRPROUUCi lO^ 11 . 1 ANY 

To Joi^ page 438. 




THE MLBT8 OF LANOBRHANS 439 

is a sweetish odour in his breath due to acetone and eventually coma 
ensues. 

The immediate treatment of eoma is essential, or the patient will die; he is 
kept warm in bed and given glucose and saline and large doses of insulin 
intravenously; if he is not comatose but only drowsy he is given insulin 
hypodermic^y, and glucose in lemonade to drink; fluid is given freely 
and he may be given a saline pvu'gative or an enema; it is always important 
to remember that diabetics should never be allowed to become consti- 
pated. The urine should be tested for the presence of diacetic acid. The 
tests for sugar, acetone, and diacetic acid are described on p. 62. 

A patient with a history of diabetes may be admitted to a hospital in 
coma, and it may be necessary to decide whether the condition is diabetic 
or insulin coma. If the patient is accompanied by a relative or friend it 
may be possible to obtain a history which will aid the diagnosis; if 
diacetic acid is found in the urine the coma can be treated as diabetic. 
Before a specimen is obtained it may be possible to make an accurate 
diagnosis by detecting an odour of acetone, by the presence of gasping 
breathir^, and by the dry hardness of the tongue, since the tongue of a 
patient in insulin coma will usually be moist. 

The treatment of diabetes. This consists in the first place of stabilizing 
treatment including if necessary the administration of insulin. A blood sugar 
estimation is made to confirm the diagnosis. The patient is put to bed, he 
is kept on a standard diet for a few days; during this time his urine is 
tested for sugar and acetone and the blood sugar is estimated. If the dia- 
betes is found to be severe he is given insulin at once but if it is not severe 
he is then given a period of starvation for 24 to 48 hours until the urine 
is sugar free. He may have fluids such as weak tea, lemonade and water 
but no sugar or milk may be given. The patient is then given a series of 
graduated diets until he is having sufficient food to enable him to live 
his normal life and perform the work he has to do without undue fatigue 
or loss of weight. During this period his urine is tested at regular 
intervals and the necessary amount of insulin is prescribed to enable the 
patient to take the requisite diet and maintain his lu-ine sugar free. 

Insulin was discovered by Bainting and Best in 1922. Since then 
there have been modifications. Soluble 
insulin was the first employed. It acts 
rapidly and the effect wears off quickly. 

Protamine zinc insulin acts slowly arid 
globin insulin has a duration of effect 
between soluble and protamine zinc 
insulin. 

Insulin is prepared in different strengths 
and all brands are packed with distinctively 
coloured labels so that everyone can rec- 
ognize the type and strength of the insulin 
he is using. 

The dose of insulin is a matter of pre- 
scription. In some cases one type and in 
another a different type is ondered. In 
certain cases soluble insulin only is 


INSOUN 


PROTAMfNE 
ZINC 
IN5UUN 
CLOBIN 
INSULIN 
(WITH ZINC) 

KzY roojuouRS 

I ' 1 B&aK5apfii!nnii 

• urr tuic Ci^CN ftrtK ykuwow 

chart or TYPRS OF INSULIN 



20 

UNITS 



Chapter 28 
Acute Infections 

V 

Irfiuenzd — Acute rheumatism — Typhoid fever — Undulant fever — Dysentery — 
Cholera — Erysipelas — Anthrax — Tetanus — Glandular fever — Malaria 
{For Infective Jaundice^ see P- 3 gs.) 

A n acute infection is due to some specific organism which results in an 
acute illness with marked prostration. In some instances, as in acute 
lobar pneumonia and erysipelas, the illness may be short and sharp, 
producing great strain on the heart and calling for the most perfect 
administration of absolute rest, and the immediate relief of symptoms. In 
other instances, as in typhoid fever and Malta fever, the illness may be 
prolonged, but the toxaemia is no less marked, and the wasting, exhaus- 
tion and prostration present necessitate the greatest possible conservation 
of the patient’s energy, in order to bring him safely to the conclusion of 
the illness, and for the avoidance of complications. 

, Many of the acute infections are infectious but, not giving rise to 
epidemics in all cases, are sometimes nursed in the wards of a general 
hospital provided the precautions described as bed isolation or barrier 
nursing can be carried out. For example, all the diseases described under 
the heading of acute infections arc infectious, and influenza is frequently 
epidemic in distribution, but most of the others mentioned occur only in 
sporadic cases in this country. It is doubtful whether acute rheumatism 
is infective or not. 

A number of diseases which arc acute infections have been described 
in other parts of the book, including pneumonia (p. 370), acute pulmonary 
tuberculosis (p. 483), acute forms of heart disease (p. 347), acute infection 
of the urinary tract (p. 398). Acute infantile paralysis, cerebrospinal fever 
and encephalitis are described in the section devoted to diseases of the 
central nervous system (see chapter 26), Acute venereal infections arc 
dealt with on p. 540. 


INFLUENZA 

Influenza is an acute infection of the respiratory tract, which may be 
slight at first, but which, because of the marked degree of toxaemia and 
prostration accompanying it, lowers the patient’s jx)wers of resistance 
and cither leads to spread of the infection or results in very serious com- 
plications. 

Symptoms. The onset is sudden^ with headache and general aching 
pains. The patient aches all over and there seems to be no part of his body 
— ^muscle, joint or nerve — that does not take part in this general ache. 

The tongue is dry and coated, the mucous surface of the fauces red 
and injected. There is a rise in temperature, and discomfort is so great 
that sleep is practically impossible. In most cases of any degree of severity 
there is aclinum. The skin is usually hot and dry, the urine scanty and the 
bowels constipated. 


44 « 



IN7LVSNZA 443 

Infastim may spread to the larynx and trachea, causing laryngitis and 
tracheiti$, and to the bronchi, causing bronchitis. A very severe form, 
which is often fatal, is influenzal pneumonia, characterized by lobular 
infection and acccxnpanied by an unusually severe and rapidly accumulat- 
ing toxaemia. On the other hand the infection may spread to the sinuses 
of the face and the mastoid antrum, giving rise to sinusitis, otitis media 
and mastoiditis. 

Other types of influenza include the gastro-intesHnal and the febrile type. In the 
febrile type the only symptom, apart from the dry tongue and injected 
fluices and general aching pains, may be a rise in temperature persisting 
for weeks, and followed by great wasting and prostration. 

In the gastro-intestinal type the symptoms of nausea, vomiting and 
diarrhoea are prominent. This results in loss of fluid and consequent 
marked dehydration accompanied by toxaemia and prostration. 

Treatment. The treatment of influenza is considered under two 
aspects. 

Prevention. Isolation of the patient is carried out. Effective ventilation is 
essential, and the windows should be wide open several times a day in 
order to ventilate the room; during this time patients should be warmly 
tucked up in bed so that they may not feel the cold. During an epidemic, 
effective ventilation must be insisted upon in the home and in the work- 
room. Travelling in crowded veliicles, and visiting places of amusement 
which are crowded, should as far as possible be avoided. It is doubtful 
whether gargling, mouth-washes, nose sniffs, or saturating handkerchiefe 
in menthol and eucalyptus arc of very much value; but, if during an 
epidemic they lessen the tendency to fear, they should be employed, and 
if a body of nurses think that gargling with ijioo carbolic is a preventive 
measure they should be encouraged to do this. If a man thinks that disin- 
fecting the mouthpiece of his telephone receiver is just the one thing 
necessary to prevent his taking influenza, let him disinfect it. Fear lowers 
the resistance of the body, and everything possible should be done to give 
the public confidence. 

The treatment of the patient depends on the severity of the infection from 
which he is suffering. The principles of treatment are: 

( 1 ) Isolation of the patient and of his feeding utensils and handker- 
chief as far as possible. 

(2) Confinement in a warm well-ventilated room. As he has a rise of 
temperature he should remain in bed; when the infection is slight he 
should remain in a sitting-room provided with a comfortable chair, a 
fire and whatevea’ recreation he pleases. 

(3) The bowels should be opened by an aperient; this depends on the 
amount of gastro-intestinal disturbance; if the tongue is coated, a dose of 
calomel may be given followed by a ssdine aperient. 

(4) The patient should be given large quantities of any fluid he will 
drii^— lemonade, barley water, aerated waters, milk and soda, tea. He 
should have about 6 pints each 24 hours. The patient may also have any 
diet he is willing to ^e. 

(5} Many physicians order some antipyretic mixture, such as aspirin or 
sotflum salicylate, in order to relieve the pains in the li^s and back, and 
so permit Am patient to go to sleep. 

The hea^cme may be due to involvement of the sinuses, and for the 



444 ACUTE INFECTIONS 

relief of this inhalations or nose sniffs may be employed. Tlic possibility of 
complications must be remembered and these should be dealt with as they 
arise. The severity of the toxaemia produces strain on the heart and, as 
influenza is followed by msirked debility, a change of air and fairly long 
convalescence with good nourishing diet should be recommended after an 
attack. 


ACUTE RHEUMATISM 

Acute rheumatism is considered to be due to a definite organism which 
is thought to be a haemolytic streptococcus. It occurs most commonly in 
children and young people, and is a disease of very grave severity. (It is 
also described as rheumatic fever.) 

Symptoms. The onset is sudden with a high temperature, headache 
and sore throat, and pains all over the body and specially in the limbs and 
joints. The skin is moist as sweating is profuse, the urine is diminished in 
quantity and constipation is present. 

The great danger of rheumatism lies in the tendency to disease of the heart; 
carditis is usually present and endocarditis and pericarditis may occur. 

Treatment and nursing. The administration of salicylates is con- 
sidered to be specific in the treatment of acute rheumatism. From lo to 
20 grains is administered every four hours, combined with a similar dose 
of sodium bicarbonate. This does not do any good to the heart infection 
which may be present, but by checking the disease may prevent the occur- 
rence of such infection. 

Mirsing. The patient should be kept in a blanket bed, and wear warm 
light woollen clothing. As absolute rest is essential, the patient must lie flat 
and keep quite still, and never be allowed to turn over or move himself 
about in the slightest. He should be moved by nurses, as all strain on a 
heart which is liable to become infected should be carefully avoided. 

As a rule the pain will soon respond to the administration of salicylates; 
but, whilst the joints and muscles are painful, it must be remembered that 
this pain is very severe and that the slightest touch accentuates the dis- 
comfort; the weight of the bedclothes cannot be borne on the limbs, and 
neither can the patient turn his head without great pain. .Such a patient 
will be seen to follow the nurses about with his eyes, which may dilate in 
horror for fear lest someone approaching his bed may touch or jar it. The 
greatest care should be taken in handling a patient who is suffering such 
pain and discomfort; the nurse must never move him quickly or hiury 
over any treatment she is carrying out for him. All her movements should 
be slow and gentle and rhythmical; her hand should be warm before she 
touches him, and she should hold him firmly but gently. 

Sponging the skin once or twice a day with hot water will often soothe 
and give relief, and it will also remove stale perspiration. A patient with 
acute rheumatism is constantly perspiring, and the sodium salicylate 
which he is having greatly increases the action of the skin. 

The diet should be very low whilst the tcrajjerature is high; diluted milk 
is given, citrated or flavoured with lemon, tea, coffee or any other flavour 
the patient likes. Whey made with lemon, and barley water slightly spiced, 
form valuable alternative drinks. In addition the patient may have as 
much water as he will take. When the temperature declines he should be 



ACUTE RHEUMATISM 445 

given a fairly liberal carbohydrate diet, but protein should be limited 
until convalescence is reached. 

The urine should be measured and daily tested for albumin, as nephritis 
may complicate acute rheumatism. The bowels should be kept acting by 
the use of mild laxatives in order to avoid constipation as the passing of a 
constipated stool is a severe strain on the muscular system and causes 
strain on the heart. 

Local treatment may be ordered for the painful joints, which should be 
wrapped in warm wool and supported on pillows and protected from the 
weight of the bedclothes by bedcradles. Deformity must be prevented, by 
the use of sandbags and splints, and plaster of paris if necessary. Prepara- 
tions of wintergreen and salicylate are employed as liniments and oint- 
ments; hot fomentations and alkaline fomentations are also employed. 

Complications. Acute rheumatism is the commonest cause of heart disease 
in young adults. Attempts are made to prevent its occurrence by the ad- 
ministration of sodium salicylate and by rest in bed. It is associated with 
sore throats and with chorea. The results of rheumatic infection on the 
heart, particularly in children, are very serious, and the very small per- 
centage of children thus affected, who reach adult life, are subject to 
chronic heart disease and so are unable to carry on their ordinary life and 
work. Hyperpyrexia may occur. 

Erythema nodosum is a condition which is associated with acute rheuma- 
tism. Nodules appear over the surface of the subcutaneous borders of some 
of the long bones, particularly the ulna and tibia, and large patches of 
erythema are seen on the arms and legs. 

The condition is accompanied by pain and fever; the tongue is furred 
and the patient suffers from considerable malaise. The treatment is rest in 
bed, warmth is essential, salicylates are administered. The possibility of 
cardiac complications has to be considered, as in rheumatism. 

ACUTE RHEUMATISM IN CHILDREN 

Acute rheumatism in children. The type of acute rheumatism which 
is characterized by a sudden onset has been described above. Two other 
types must be mentioned — (i) in which chorea is the most marked symp- 
tom, and (2) in which the onset is very insidious. 

The latter is the more commonly met with in children who are affected. 
The child may have growing pains, or complain frequendy of sore throat. 
He may lose a litdc weight, be disinclined to eat, have a slight rise in 
temperature with some increase in the rate of the pulse, or it will be 
noticed that he is resdess during sleep, or pale and lisdess, or slightly 
dyspnoeic or cyanosed. 

The treatment of acute rheumatism is always on the same lines, that is, 
the administradon of salicylates and rest in bed. 

Preoeniive treatment is very important, and to effect this the earliest signs 
should be dealt with, a child in whom any of the symptoms mentioned 
above are manifest being at once examined by a heart specialist. 

If acute rheumatism is suspected he should be kept in bed and treated; 
if no active signs of any cardiac lesion are present, he may be given gentle 
graduated physical exercises in bed, and then allowed to get up, for a 
short time at first, taking the same care as described when getting any 
patient up, after he has had heart disease. 



446 ACUTE INFECTIONS 

Special schools are available for the accommodation of children with 
rheumatism, in whom cardiac disease may be anticipated. At these schools 
they can be nursed, treated and educated at the same time, and they arc 
protected from the full energetic life of a child in a house full of other 
children, or in a school where the routine is regular but rather strenuous. 

See Chronic Rheumatism, p. 784. 

TYPHOID FEVER 

T^^ihoid fever is an infecdous disease due to the bacillus typhosus. It is one 
of a group — the enteric group — the others are known as paratyphoid fever, 
types A, B and C. The differences between these diseases are only bac- 
teriological, as the symptoms and the course of all four of them are similar 
and one is not necessarily more or less severe than another. As far, there- 
fore, as the nursing is concerned, each of them needs exactly the same 
careful attention. The disease is characterized by inflammation and ulcera- 
tion of the Peyer’s patches in the small intestine and caecum. 

Infection may be direct or indirect, by means of food, or carriers of the 
disease, and the incubation period is from 10 to 21 days. 

Symptoms. The onset is slow and insidious. The patient suffers from 
malaise, loss of appetite, abdominal discomfort and a severe frontal head- 
ache. There may be epistaxis. After about a week, he feels ill enough to 
stay in bed; his temperature rises, taking 4 or 5 days to reach 103° or 
104® F., since it rises two degrees each evening and then falls one degree 
each morning. (See the illustration on p. 35.) 

The disease is now advancing, the abdomen is large and doughy, and 
there may be diarrhoea, though constipation is more often a feature of the 
disease. The patient feels sick and may vomit, his skin may be dry or he 
may sweat profusely, and he suffers from considerable thirst, his mouth 
being dry and his tongue coated. By the seventh day the rash usually 
appears. 

The rash is compKised of discrete rose-coloured papules which disappear 
on pressure. There may only be two or three, or a number, 20 to 30, may 
be seen, and they appear on the abdomen, flanks and thighs. They last 3 
or 4 days and then fade; successive crops may appear every 2 or 3 days for 
a week or so. 

The patient is now well into the second week of the disease, and the 
symptoms become more marked. If there is diarrhoea, the stools will pre- 
sent the characteristic yellow ochre colour and pea soup consistence, being 
offensive and containing curds of milk and undigest^ fat. The urine is 
scanty and high coloured and may contain albumin. The pulse is soft and 
of low tension, and may become dicrotic. 

Toxaemia is marked, the patient lying listless in his bed, flat on his back, 
with a colour suggestive of grave toxaemia and a hectic flush on each 
check. His mouth is very dry, the tongue covered with dry brown fur and 
the teeth and lips with sordes. He gets weaker and weaker and Anally 
sinks into what is described as the typhoid state, characterized by low mut- 
tering delirium with constant involuntary plucking at the bedclothes. The 
eyes are held wide open, as if staring at the ceiling (coma-vigil). 

The end of the second week has now been rea<^ed and the dreaded 
complications of haemorrhage, due to the erosion of a blood vessel by the 



TYPHOID FEVER 447 

deqily sloughing ulcer, or penetration of the wall of the intestine (perfora- 
tion) may occur. At this period there may be remissions in the fever and 
gradually, if the illness terminates satisfactorily, the temperatiure declines 
and the toxaemia and other symptoms abate. 

During the third wedt the patient begins to feel better and his tempera- 
ture falls by a fairly long lysis. He is very weak and hungry, demanding 
food which will probably be denied him and possibly being very irritable 
and discontented in consequence. 

The complications arc numerous. Haemorrhage and perforation and 
toxaemia have been mentioned. Severe abdominal distension may be a compli- 
cation. Bronchitis and pneumonia may occur. Septic parotitis may result from 
poor oral hygiene. Otitis media, cholecystitis, periostitis, and osteomyelitis and 
the formation of boils, carbuncles and abscesses may arise. Phlebitis and throm- 
bosis of the veins of the legs may arise as the fever declines. Abortion occurs in 
pregnant women. Two rare complications mentioned in most textbooks 
are typhoid spine, which is a spondylitis, and tender toes, which is a sensitive- 
ness of the skin over the toes, due possibly to neuritis. 

Treatment and nursing. The principles of treatment are dictated by 
the length of the illness and the severity of the toxaemia from which the 
patient suffers and by the possibility that serious complications, perfora- 
tion and haemorrhage, may occur. 

Good nursing is essential, the patient being nursed in a sheet bed, and great 
attention paid to the skin for the prevention of bedsores and the removal 
of perspiration. Rest should be as definite as possible, the patient being 
nursed fairly flat, with his back and thighs — which ache severely — sup- 
ported during the first ten days; footdrop must not be allowed to occiu:. 

The patient should be moved every 2 or 3 hours, as movement helps to 
prevent the possibility of pneumonia, and also to prevent the retention of 
flatus which may result in very severe abdominal discomfort. It is essential, 
however, that the patient should not be allowed to make any effort himself. 

The mouth needs frequent attention in order to keep it clean, and the 
swabs used should be destroyed at once; and, as retention of the urine may 
occur, it had better be measured to make sure that the patient is passing a 
normal amount. 

The bowels require attention if they are constipated, and some physi- 
cians order liquid paraffin to be given in small doses, three times a day, 
while others prefer that the bowel action should be regulated by the ad- 
ministration of small, carefully administered, olive oil or glycerine and 
water enemata. 

The diet will be definitely ordered, but in most cases the patient is kept 
on a limited amount of nourishment, 2 to 3 pints of milk — given diluted 
with water — and ^ to i pint of beef tea, or chicken soup. Unless instruc- 
tions are given to the contrary the nurse should strain all feedings. (For the 
management of a fluid diet see p. 270.) 

In addition, water and lemonade containing glucose may be given in 
quantity, and the patient should be encouraged to drink at least three 
pints of such fluid a day, in addition to his feedings. 

The diet may require very much modification during the course of the 
illness; should there be excessive abdominal distension and diarrhoea it 
may be necessary further to dilute the milk, or even to citrate or peptonize 
it and it may become necessary to omit the meat broths. On the other 



44® ACUTE INFECTIONS 

hand, if the patient is less seriously ill, he may be able to have thickened 
(strained) food and jelly, and junket and custard even before his tempera- 
ture has declined. 

Any symptoms which are distressing should be relieved as much as pos- 
sible; an icebag or cold compress may relieve headache; restlessness may 
be obviated by sponging the skin, changing the position of the patient in 
bed, altering the arrangement of the bedclothes, shading a light and all 
the other little attentions a good nurse would instinctively offer. 

As thirst is often intense, and the mouth very dry and sore, the adminis- 
tration of fluids will help, and a few sips every few minutes will help to 
keep the mouth moist. 

The temperature should be taken every 4 hours and the pulse observed 
more frequently. Sleep is very necessary and the nurse should never waken 
the patient either to take his temperature or to give him a feeding; she 
should, however, be ready at hand with a drink as soon as he wakens, 
because on wakening from a sleep the mouth, in typhoid fever, is always 
very dry. 

When the temperature declines the diet will be increased; a little fine 
bread and milk may be given; some thickened milky foods, jellies and 
custards are added at first, and then, after about a fortnight a little 
steamed fish, pounded chicken, potato and milk pudding may be added. 

Disinfection and isolation are important points in the nursing of 
typhoid fever cases, and the method of bed isolation or barrier nursing is 
usually employed. Certain articles should be kept separate for the patient, 
including his washing, toilet and feeding utensils and articles, and a 
clinical thermometer. 

The nurse or doctor will not handle the patient or his bed or utensils 
unless wearing a coat, and they must remove the coat and wash, scrub and 
disinfect their hands after touching him. 

Everything that is removed from the patient’s bed or used for him must 
be adequatdy disinfected, preferably by boiling; his excreta, secretions 
and discharges should be covered with disinfectant and allowed to stand 
in it for at least an hour before being disposed of. This ako applies to 
bedclothing soiled with excreta — ^it must be soaked before it is sluiced. 
The bedclothes, all personal clothing, towek, &c., should either be soaked 
in disinfectant or steam sterilized before being sent to the laundry. 

The nurse must spare no pains to prevent the spread of infection, cither 
to others or to herself. She must take the greatest care in washing and 
scrubbing her hands; she should keep the skin soft, so that crack and 
chaps do not occur. It would be ideal if she could be persuaded not to 
handle her own food, or any food, except the patient’s, with her hands. 
She should cat with a knife and fork, using these for bread and butter, 
cake and everything she conveys to her mouth. 

A point that nurses often forget is the long range of infection from a 
patient who is coughing, and the even greater range of one who may be 
vomiting. The greatest care should be taken, whikt helping and supporting 
the patient during either of these acts to keep out of the range of droplet 
infection, as all secretions, as well as excretions arc highly infectious. 

Gonvalescence is a very trying time for a patient who is approaching 
the end of a long illness. He may now be rais^ on pillows and should be 
encouraged to move his legs and arms. After his temperature has been 



TYPHOID FEVER 449 

down for about a fortnight he will be allowed to get up, for a very short 
time — about 15 minutes the first day — and gradually increase the effort 
he is allowed to make as he gets stronger. He must never be allowed to 
become tired as this might be followed by indigestion and sleeplessness 
which would /urther retard his recovery. 

Complications will be treated as they arise. In the event of haemorrhage^ which 
will be accompanied by a sudden drop in temperature, a weak, thready 
pulse and cold, clammy skin, the nurse should send for the doctor, and in 
the meantime elevate the bedclothes from the abdomen by means of a 
cradle, refrain from giving anything by mouth, continue to moisten the 
patient’s lips, see that he is not cold, and give him a hot water bottle or 
two if he feels cold. She should reassure him; but if he demands the bedpan 
she should avoid giving it as this would mean moving him, and she should 
arrange to receive any stool on pads of wool and tow. 

In the event of perforation^ the nurse should send for the doctor, give the 
patient nothing by mouth and unobtrusively prepare for taking him to 
the operating theatre. In the meantime his relatives should be sent for. 

The Widal test* The Widal — or agglutination — test or reaction is used 
as an aid to diagnosis in typhoid and paratyphoid fevers, in some forms of 
dysentery and in cholera and Malta fever. It depends upon the known fact 
that the presence of agglutinating substances in the blood of patients suf- 
fering from cither of these diseases will cause clumping or agglutination of 
the germs, if the blood serum and organisms arc placed together. 

A specimen of blood is taken and allowed to clot. The serum is diluted 
in a variety of different strengths; an emulsion of the germs is then added 
and the result watched by the aid of a microscope; the amount of dilution 
which will produce agglutination suggests the agglutinin content of the 
blood. It is important to note that the test is specific, since the serum of a 
patient with typhoid fever will not agglutinate any other bacteria, while 
the scrum of a patient with paratyphoid ‘A’ (for example) will not agglu- 
tinate the organisms of paratyphoid ‘B’. The scrum of persons who have 
been inoculated against a disease will contain agglutinins, and conse- 
quently give a positive reaction to this test. 

UNDULANT FEVER 

Malta or undulant or abortus fever is a disease transmitted to man from in- 
fected animals — goats and cattle — by means of milk, butter and cheese. 
Abortus fever is due to Brucella abortus and Malta fever to Brucella Meliten- 
sis. The incubation period is 5 to 1 5 days. 

Symptoms. The onset is insidious, and is accompanied by vague pains 
in the limbs and back, headache and a rise of temperature. TTie fever rises 
gradually, taking about a week to reach its maximum, as in typhoid fever, 
and then continues for two weeks; it is remittent in character. 

During the course of the disease the patient suffers from exhaustion with 
great thirst, has no desire for food and his mouth is very dirty. He sweats 
profusely and is unable to sleep. He becomes very weak, wasted and 
anaemic. 

Malta fever is dcpressii:^, debility is very marked and the inability to 
sleep renders the patient miserable. The temperature usually declines 



450 ACUTE INFECTIONS 

after two wedcs, and there is then a period of fireedom from fever, but it 
rises again and recurrences of fever may be expected for many months. 

Treatment and nursing. A specific vaccine is employed. Apart from 
this, treatment aims at the relief of symptoms. As far as nursing is con- 
cerned a patient suffering firom Malta fever requires exactlythe same care 
as a case of typhoid, except that the diet need not be restricted. The patient 
should be given plenty of fluids containing glucose, and persuaded to take 
as much noiurishment as he will, in whatever form he likes. 

The infection is carried by the secretions and excretions and these should 
be disinfected before disposal. The patient must be kept in bed whilst he 
has a high temperature; m between the attacks of fever he may get up; he 
should be kept as happy and cheerful as possible and can be promised that 
he will get better eventually, and told that in the meantime it is wisest to 
try and make the best of the intermittent periods, when he is free from 
fever, in order better to conserve his strength against the recurrences that 
must be expected. 

He should be brought to see that as he gets stronger the attacks seem to 
be shorter and that one of them will really be the last, and that then he will 
be free from the tiresome disease. He needs all the help that can be given 
him as a long tedious illness, characterized by prostrating bouts of fwer, 
is trying even to the most courageous temperament. 

DYSENTERY 

Bacillary or epidemic dysentery is characterized by blood and mucus in the 
stools and is due to two organisms, Flexner’s and Sonne’s bacillus. Shiga’s 
bacillus causes a tropical dysentery. 

The incubation period is short, from a few hours to a week. There is acute 
inflammation of the lining membrane of the lower part of the ileum and 
the large intestine. 

Symptoms. The onset is sudden, with abdominal pain and diarrhoea, a 
rise in temperature, rapid pulse, thirst and vomiting. Tenesmus or strain- 
ing at stool is frequent and distressing; a small quantity of blood and 
mucus is passed each time and the stools are entirely devoid of feculent 
matter. 

Bacillary dysentery may be acute, as described above, or a mild or a 
chronic form may be seen. In the acute form the patient becomes rapidly 
prostrated, dehydration is marked and he is cold and collapsed. 

The treatment during this stage is to keep the patient warm in bed, 
make hot applications to the abdomen in order to try and relieve pain, 
while sedatives are given to help the patient to get some sleep, and starch 
and opium enemata are employed for the relief of tenesmus. 

The diet is very restricted during the acute illness; milk should be 
omitted, albumin water, and watery drinks containing glucose are used as 
nourishment, and the patient should be given small (brinks of water fie- 
quently in order to allay thirst and provide him with fluid. 

The administration of a polyvalent scrum is employed, but it must 
given early in the disease or it is of little value. 

In the nursing care of bacillary dysentery isolation is essential. This form 
of dysentery is carried in the same way as typhoid fever, and the exeteta 
must therefore be covered with disinfectant and allowed to stand for an 



DYSENTERY 45 * 

hour before being disposed rf. The bed and personal clotlung of the patient 
should be disinfected before being sent to the laundry. The doctor and 
nurses must wear coats over their clothing before handling the patient or 
his utensils and they should wash and carefully disinfect their hands after- 
wards. 

The dry mouth and thirst is a distressing symptom which the nurse 
should attempt to relieve by frequently cleaning the mouth and giving 
small drinlcs of water. The skin of the patient must be kept clean and free 
from soreness; he will become very thin and must be protected from pres- 
sure of the bedpan if one is used. To prevent the area around the anus 
from becoming sore, it should be cleansed with soft wool and carron oil 
(e^al parts of linseed oil and lime water) after stool, and the swabs burnt. 

During the stage of acute illness in severe cases the patient becomes 
exhausted and collapsed and may sink into the state described in typhoid 
fever as the typhoid state, when he lies quietly muttering and plucking at the 
bedclothes. 

Very acute bacillary dysentery runs a comparatively short course, and 
if it terminates fatally the patient will only live for a few days. When the 
disease terminates satisfactorily the stools will be seen, after a week or lo 
days, to contain some feculent matter, and this is satirfactory as it will be 
accompanied by decrease in the frequency of the stool, decline of fever, 
improvement in the pulse and gradual abatement of the symptoms. 

As soon as improvement is definite the diet may be gradually increased. 
Citrated or peptonized milk may be given, jelly, lighUy steamed custard, 
a little crustless bread and butter and steamed fish pounded. Any return 
to the state of dysentery would indicate reduction of the diet. 

A new sulphonamide drug, sulphaguonidine, is being tried with success in 
the treatment of some of the intestinal infections, including bacillary 
dysentery. 

Amoebic dysentery — known also as tropical dysentery — is caused by 
protozoa, and spread by flies, contaminated water and carriers of the 
disease. 

In acute amoebic dysentery the onset is abrupt, with abdominal pain 
and diarrhoea. Unlike the temperature in epidemic dysentery, that in this 
variety is not very high. In severe cases the disease may terminate fatally 
within a week, but in the majority of cases the condition becomes chronic. 

Subacute or chronic amoebic dysentery may follow an acute attack or 
it may have commenced gradually with symptoms of indigestion, vague 
abdominal discomfort, lisdessness and headache. Amoebic dysentery may 
be complicated by liver abscess. 

The treatment of amoebic dysentery is by emetine which is an alkaloid 
of ipecacuanha. 

Prevention of dysentery. The stools must be disinfected, and all precautions 
taken to keep the utensils tised by the patient separate a^ to disinfixt 
his linen before it is washed. Food must be protected from flies and, during 
an epidemic, very careful supervision should be made of persons who 
handle food. It is important also to safeguard the water supply from con- 
tamination. 

GHOI.ERA 

Cholera is an acute epidemic tropical disease due to V. choleras or the 
cholera bacillus. It is spread by carriers and by infected food, water. 



452 ACUTE INFECTIONS 

milk and also very lai^cly by flics. The incubation period varies from a 
few hours to several days. 

Symptoms. The onset is sudden. Diarrhoea and vomiting are present 
and even in the early hours of the disease in severe cases the patient is 
passing copious watery stools. These contain little flakes of epithelium 
from die mucous lining of the intestine which give to the pale watery 
stools the appearance of “rice water’’. 

The patient becomes rapidly dehydrated and very collapsed, the 
temperature is subnormal and the pulse weak. In many instances the 
patient is pulseless. This condition persists for 24 to 36 hours when 
improvement may be seen. The stools become less continuous and less 
frequent, the skin improves in colour and the temperature rises to loi^’, 
or 103° F. In a few cases hyperpyrexia occurs. 

The complications which occur are cardiac failure, suppression of urine, 
pneumonia and septic conditions of the mouth. 

Treatment and Nursing. The patient should be kept quiet and nursed flat 
in bed. He must not be allowed to do anything for himself, all exertion 
must be carefully avoided because of the danger of heart failure. External 
applications of warmth, blankets, cradles and hot bottles will help to 
treat the severe collapse from which the patient is suffering. Hot stupes 
to the abdomen will relieve the cramplike pains. It is important to note 
and measure the amount of urine passed so that any tendency to suppres- 
sion may be observed without delay. 

The ^ministration of fluid is important. Saline and glucose arc given by 
parenteral routes. As soon as vomiting abates the patient may be given 
fluids such as water and glucose, whey, and later when the diarrhoea 
ceases he may have diluted milk. Diet can only be very judiciously intro- 
duced, arrowroot is a good beginning and the patient can then be given 
light carbohydrate diet. Protein should be given with caution until 
renal function appears to be normal. 

Convalescence is fairly rapid. The patient should be careful for some 
time as any sudden movement may result in heart failure. 

Medicines and Drugs, Kaolin is given in large doses as long as diarrhoea 
persists. Chlorodyne and morphia are ordered to relieve abdominal cramp. 
Ktuitrin and pitressin arc given to raise the blood pressure. 

Precautions against spread of infection. The patient should be isolated 
and the precautions taken in nursing typhoid fever should be applied 
to cholera. 

In countries where cholera is prevalent and in any country where 
an epidemic occurs very great care should be taken in the preparation 
of water and milk ^ould be boiled before use, green salads and 
uncooked finit and vegetables should not be eaten uidess they can be 
peeled, cleanliness and the importance of washing the hands before 
eating should be stressed, all food should be protected from flies. Flics 
should be eliminated as far as possible. 

ERYSIPELAS 

Erysipelas is an acute infectious disease characterized ^ swelling and 
redness of the skin and mucous surfaces which may be affected, and ac- 
companied by a very high degree of temperature. It is due to a hacmyldtic 
streptococcus. 



ERYSIPELAS 453 

Jf^ection occurs by inoculation of a wound or abrasion of the skin, though 
this may be only ndcroscopic. It is highly infectious to wounds and ob- 
stetric cases, and therefore has to be strictly isolated whenever it occurs in 
the wards of a general hospital. The incubation period is from 2 or 3 days to 
7 or 8 days. Erysipelas may attack any part of the body, but the face, in 
which the skin is exposed, is most often the site of inoculation. The disease 
frequcndy commences at the inner canthus of the eye, or the margin of 
the nose, where the mucous and skin surfaces meet. 

Symptoms. The onset is sudden, there may be rigors and shivering, 
headache, sore throat, vomiting and a high temperature, 103° or 104° F., 
with a rapid pulse. 

The rash is a dull red colour; the skin is tense, swollen and shining, with 
a raised margin which denotes the area of rapidly spreading rash. The 
surface of the rash may be covered with blebs and bullae. When the face is 
affected, if the rash begins at the margin of the nose, it spreads over the. 
face, butterfly fashion, and up over the forehead and on the scalp. The 
whole of the scalp may be invaded. The eyes are closed, the lids swollen,, 
the ears thick and the face so disfigured by swelling that the features may 
be unrecognizable. 

Headache is very severe, and there is usually delirium; the pulse is rapid,, 
the temperature remains high, and the patient is unable to sleep because 
of the severe headache and great discomfort he is suffering. The tempera- 
ture usually persists for a week or 8 days. During this time the patient is 
passing through a very serious illness, his heart may fail, cyanosis is a 
serious sign, and prostration becomes more and more severe as the patient 
becomes weaker and is unable to withstand the toxaemia and discomfort 
from which he suffers. 

The temperature declines fairly rapidly at the end of the illness, in an 
uncomplicated case, usually by crisis or a short lysis; when suppuration 
occurs, the temperature becomes intermittent in character and persists for 
longer. 

The complications of erysipelas are suppuration, sloughing, and 
cellulitis of the tissues, adenitis of the local lymphatic glands, toxaemia and 
pyaemia; broncho-pneumonia may occur, especially in elderly persons, and 
marua may follow severe delirium. 

Treatment and nursing. Isolation of the patient is necessary, and 
great care must be taken to avoid transmission of the infection to surgical 
and obstetric cases. A nurse looking after a case of erysipelas should not 
touch surgical cases. 

The patient is kept in bed, in a warm quiet room, and his headache may 
be relieved by aspirin, his temperature by sponging, and his thirst by the ad- 
ministration of fluids. The diet should be fluid, up to 3 pints of nourishing 
fluids being given daily and, in addition, several pints of watery drinl» 
containing glucose. The mou^ should be cleaned, the urine measured and 
tested for albumin and the bowels kept acting regularly; the usual atten- 
tion for the prevention of bedsores is necessary, and elderly patients should 
be moved imrly frequently in order to obviate the danger of hypostatic 
pneumonia. As the duease is severe and exhausting, stim^ants are usually 
given and sedatives employed to induce sleep. 

Some local treatment vm usually be ordered; painting the skin with gly- 
cerine and ichthyol helps to allay inflammation and to relieve the tense- 



454 ACUTE INFECTIONS 

ness, of the tissues. Applications of hypertonic saline compresses, provided 
the inflamed skin is anointed with oKve oil or liquid paraffin, will reduce 
swelling. Some physicians prefer to keep the skin dry and order it to be 
dusted with a mildly astringent powder; others like it to be painted with 
a weak solution of iodine. 

The administration of the sulphanilaroide compounds (see p. 327) is 
proving successful in cases of erysipelas. 

Convalescence. Once the temperature has declined and the rash dis- 
appeared, the patient will make rapid strides towards convalescence. He 
should have a change of air, a good nourishing diet, and a little stimulant 
such as whisky or port wine to increase his resistance and hasten his re- 
covery from the anaemia and debility which follow this short serious 
illness. 

The skin will be tender and delicate for some time, and should not be 
exposed to the injudicious use of strong soaps or to biting winds. It is better 
to teach the patient to cleanse his skin with olive oil, or oatmeal and water, 
and it must be well dried and any abrasions or cracks treated with healing 
ointments. 

It is important to remember that one attack of erysipelas predisposes to 
others — immunity is lowered, not raised. 


ANTHRAX 

Anthrax is a disease due to a spore-forming organism, the bacillus anthra- 
oj. It is transmitted to man from infected animals in hides, wool and hair. 
Men unloading hides and wool at the docks may be infected. The incuba- 
tion period is short, from i to 3 days. 

There are two varieties of the disease — external anthrax or malignant 
pustule, which is the result of inoculation; and internal anthrax, when the 
organism is inhaled. The latter may be characterized by acute pulmonary 
or abdominal symptoms, accompanied by severe prostration, and usually 
terminates fatally within 48 hours. 

External anthrax or malignant pustuUt which is the type most commonly seen, 
usually appears on the exposed parts of the body, face, neck and arms. 

It begins as a pimple surrounded by an area of inflammation; in a few 
hours the pimple is encircled by an area of induration which is covered 
by yellow blebs and surmounted by, a black, scab from which the name — 
malignant pustule — is derived. The skin for a considerable area around the 
lesion is livid, tense and swollen. 

The constitutional symptoms present demonstrate the severity of the 
toxaemia from which the patient is suffering; in a day or two from the 
onset, ip an untreated case — and because of the cardiac failure and as- 
phyxia which accompany the severe toxaania — the temperature is high, 
the pulse rapid and the patient lividly blue, delirious and gasping for 
breath. 

Treatment and nursing, The only treatment of miy use is the early 
administration of the specific anti-antbrax. serum in sufficiently large 
doses. This is followed by decline of the local inflammation and abate- 
meat , of the consfitutional symptoms, Serum is repeated until .the tempera- 
ture has declined. 



ANTHRAX 455 

^ In the nursing care the high degree of infectivxty must be taken into con- 
sideration. A nurse attending a case of anthrax should not have the care 
of any surgical case. She must protect the skin of her own hands by wearing 
rubbia' gloves; if her skin becomes abraded she should be removed from 
the case. Infection will be transmitted to her from any slight abrasion on 
the patient’s skin or from any article, such as a hypodermic needle, which 
may have been used for him. She must keep her nails short and neat, and 
wash and disinfect her hands carefully for fear of inhaling or ingesting the 
organism with her food. 

As far as possible old bedding and clothing, which can be destroyed 
after use, should be provided. 

The symptoms will be treated as they arise, and the patient requires 
constant care during the acute stage when he is livid, dyspnoeic and delir- 
ious. Oxygen is administered continuoiisly, and fluids should be given 
liberally by whatever channel is convenient. In very severe cases contin- 
uous intravenous infusion of fluid is employed. 


TETANUS 

Tetanus, like anthrax, is a disease due to a spore-forming organism. 
This organism lives in the intestines of grazing animals and is deposited in 
their droppings, so that man may be infected by road dirt, and also by the 
intestine of the sheep in prepared catgut and by animal wool. The length 
of the incubation period depends on the virulence of the infection, it varies 
from 24 hours to several weeks. 

In tetanus the organism, having gained entrance to the body by inocu- 
lation, multiplies and pours its toxins — ^which have a selective action on 
the central nervous system — into the blood stream, and this is manifested 
by rigidity of the skeletal muscles. 

Symptoms. At first the patient complains that he finds it difficult to 
open his mouth — this is why tetanus is sometimes called lockjaw. The 
facial muscles arc contracted in a grin, described as risus sardonicus. As the 
condition becomes worse, spasmodic contractions of the muscles occur and 
the patient’s body is contracted, his head retracted and back arched. The 
intercostal muscles are also contracted and this results in dyspnoea. These 
muscular spasms cause great pain, the patient is very cyanosed, his skin is 
covered with a cold sweat, and he becomes rapidly exhausted. Death 
occurs from heart failure in untreated cases. 

Treatment and nursing. The only treatment of any value is the early 
administration of anti tetanus serum, in large doses. Unfortunately con- 
siderable damage may have been caused to the central nervous system as 
the result of infection by tetanus before any symptoms are seen, and the 
administration of serum will not repair this damage. 

The adminBtration of antitetanic senun is employed as a prophylactic 
measure in all cases admitted to the casualty department of a hospital 
with injuries or wounds which are contaminated by road dirt, and as a 
prophylactic it is considered invaluable. 

In the nursing care of a patient with tetanus, isolation is essential and the 
nurse attending him should not have charge of any surgical case. 

Hie patient should be nursed in a quiet well ventilated room and, as 
even slight extenud stimuli will provoke a muscular iqiasm, the bed should 



456 ACUTE INFECTIONS 

be approached quietly and the patient touched gently, allowing him to 
become accustomed to the weight of the nurse's hand very gradually. Her 
hand must be warm, not cold, and the grasp should be gentle, even amd 
firm. All moving of the patient should be slow and rhythmical, but he 
should be moved as little as possible and must not be ovemursed. He 
should be washed only as much as is absolutely necessary and, although it 
is most desirable to prevent the formation of bedsores, yet here again the 
least possible handling and treatment should be employed. 

Most physicians will order sedatives in sufficient quantity to keep the 
patient in a stuporous condition, and in some instances avertin is employed 
for this purpose. When spasms arise in these circumstances, they arc con- 
trolled by inhalations of chloroform. 

It is very important to get as much fluid as possible into the patient, and 
when he is kept in a stuporous state this is usually managed by means of 
continuous rectal administration and in severe cases fluid is given intra- 
venously. 

The nurse must watch the patient’s colour and pulse, measure his urine 
and compare the output with his fluid intake. His bowels should be kept 
acting, and his tissues must be watched for oedema, as this would indicate 
failure in the circulation of his body fluids — probably because his heart had 
begun to fail. 

When death occurs it is due to toxaemia and cardiac and respiratory 
failure. As already stated, the only treatment of value is the administration 
of antitetanic serum, but a nurse can assist the patient throughout the 
course of this serious disease by helping to avoid muscular spasm, by main- 
taining him in a state of rest and quiet and by the liberal administration 
of fluids. 


GLANDULAR FEVER (Injective mononucleosis) 

Glandular fever is an acute infection, but the causative organism is not 
known. The incubation period is from five to fourteen days. Infection is due 
to droplet infection and close contact with the patient. Three types of the 
disease are described: 

An angiose type characterized by sore throat. 

A febrile type in which fever and a rash occur, and 

The glandular type characterized by painful swellings of the lymphatic 
glands. This is the commonest type. 

In the glandular type the onset is marked by malaise, headache, general 
pains and a rise of temperature. In some cases tonsillitis occurs, Epistaxis is 
occasionally seen. The spleen is enlarged. The disease runs a course of about 
two weeks during which the temperature remains elevated, ranging from 
1 01 to 102, or even 104 degrees Fahrenheit in some cases, and then de- 
clines, but relapse may occur and in many instances there is a rise of tem- 
perature in the evening for some weeks after decline of the initial fever. 

Diagnosis is made on blood counts and special blood tests. There is an 
increase in the white cell count with a high percentage of monocytes (mon- 
ocytosis). The Wassermann reaction is positive in about fifty per cent, of the 
cases and therefore the possibility of syphilis has to be excluded. A special 
blood test — the Paul and Bunnell test — ^is based upon the known fact that 
the blood serum of a patient suffering firom glandular fever will cause 
sheep’s red blood cells to agglutinate. 



GLANDULAR FEVER 457 

Treatment and Nursing. The patient is kept in bed during the acute 
stage and should be isolated for about two weeks, or until the temperature 
has declined. Ordinary nursing measures are necessary, the diet should be 
fluid and the bowels kept acting regularly. A fairly long convalescence is 
necessary, and debility should be counteracted by tonics and nourishing 
diet. 


MALARIA 

Madaria is a disease which is conveyed from man to man by an 
anopheles mosquito. This insect sucks the blood of its host and at the 
same time injects the malarial parasite into the blood stream. After 
an incubation period averaging from ten days to a fortnight but which may 
be considerably longer, the onset of the disease occurs with a rigor. 

Types of malaria. The simplest form and the one which is used in the 
malarial tlierapy of general paralysis of the insane (see p. 37) is benign 
tertian. This variety is characterized by a rigor on alternate days. 

Qjiartan malaria is characterized by a rigor every third day. 

Malignant tertian is a more serious type and one which may present a 
variety of symptoms. In some cases there is continuous high fever with 
delirium and prostration. In others it may take the form of algid collapse 
again accompanied by severe prostration. A cerebral type of malaria is 
also met. The patient complains of headache, he becomes rapidly pros- 
trated with marked hyperpyrexia and lapses into unconsciousness. 

Treatment. The successful treatment of malaria is of comparatively 
recent date. Patrick Manson in 1878 discovered that an embryo fllaria 
from a man could develop in a mosquito; Ronald Ross in 1898 dis- 
covered that malaria was spread by an anopheles mosquito and he 
taught the necessity of eliminating the mosquito by destruction of its 
breeding places if the incidence of malaria was to be reduced. 

Treatment by cinchona bark is several centuries old and preceded the 
use of quinine which is a pure alkaloid of cinchona. Quinine is still the 
drug of choice. It is used as an anti-malarial measure and in the treat- 
ment of malaria. In the treatment of benign and quartan malaria, quinine 
sulphate or hydrochloride is given by mouth in doses of i o to 1 5 grains three 
times a day after food. Children receive proportionately smaller doses. A 
child of two years may have i or 2 grains, increasing up to 5 grains for a 
child of seven years. 

The severer infections which are usually due to malignant tertian are 
given injections of quinine. A special preparafion of quinine is put up in 
phials of 7^ to 10 grains in sterile water. These are given in saline by the 
intravenous route. A dose of 5 minims of adrenalin should be at hand in 
case the blood pressure falls during administration. 

Qjiinine may also be given by the intramuscular route. The gluteal 
region is chosen. The injection must be given deep into the muscle 
or necrosis of tissue will occur. If injected too low in the gluteal region 
paralysis of the great sciatic nerve may be caused. 

The treatment of malaria by quinine is always accompanied by micro- 
scopical examination. The result of the initial examination of the blood 
wiu assist the physician in deciding on his method of treatment and the 
amount of quinine the patient needs. In order to prevent relapse treat- 
ment by quinine is continued for a week or more after cessation of 



458 AQUT^ PIFEOTIONS 

fever. Chronic relapsing malaria may be th? remilt of failure to observe 
this precautionary measure. A synthetic preparation of quinine, plasmo- 
quinine, has proved of value in treating these chronic cases. 

Alternative Drugs. Atekrin is a drug which is employed in some cases, 
it may not, however, be given to children under 8 years of age. Sul- 
phonamides are also being used. 

patient suffering from malaria is given a dose of calomel at the 
outset, followed by a saline aperient. The bowels should be kept acting 
well dining the time that quinine is required. Any symptoms due to 
quinine (see p. 293) should be noted. Headache may be treated by 
aspirin. When the temperature is so high that it is causing grave re$dess> 
ness and discomfort the patient may be tepid or cold sponged to relieve 
this. 

After an attack of malaria the general state of health will be low, the 
patient becomes anaemic, he loses his appetite and gets thin. Arsenic and 
liver preparations are given to treat the anaemia. The appetite should be 
tempted and good nourishing food supplied. Convalescence should be 
long and effective, if this is not attends to there is danger that relapse 
will occur. 

Prophylaxis. Anti-malarial measures should be insisted upon for those 
who are resident in a malarial infested country. Nurses working with 
the troops should do all they can by their own example, which is the 
best form of propaganda, to teach the importance of: 

Avoidance of camp litter and destruction of the breeding places of 
mosquitoes 

The importance of maintainiug a high standard of health and a very 
high state of anti-malarial morale 

The necessity of using mosquito nets and protective clothing, such as 
mosquito Ixtots 

The value of quinine as a suppressive measure and the need for perse- 
vering with its use. 



Chapter 29 

Louse-borne Diseases 

Introduction — Epidemic typhus fever — Epidemic relapsing fever — Trench fever 

T he three'diseases described below are transmitted by lice, as the term 
louse^borne infection implies. They tend to occur when louse infestation 
of the population increases as happens under conditions of war. It 
would be ideal to prevent the conditions under which these diseases prevail, 
but whilst this is not always possible prophylactic measures, which consist of 
thorough disinfestation or ‘delousing’ of the patient and as far as possible 
of contacts, and the use of protective clothing by doctors, nurses, and 
attendants, should always be employed. 


PROPHYLAXIS 

Typhus fever is the infection most likely to give rise to an epidemic in 
this country under present war conditions, and the preventive measures 
planned to deal with this disease would be adequate also in dealing with 
either of the other louse-borne infections, 

(1) The disease u made notifiable to the Medical Officer of Health. 

(2) Specially trained teams to deal with afi outbreak have been organize. 

(3) The services of medical men well versed in the early recognition 
and treatment of typhus have been requisitioned. 

(4) Protective clothing consisting of a one-piece garment closed by zip 
fasteners, with gloves and gumboots is issued to doctors, nurses and 
attendants handling patients prior to, and during, delousing. 

(5) In conveying cases from house or barracks to hospital it is recom- 
mended that the patient should be enveloped in a sheet over his own 
clothing, as lice do not move easily on smooth fabric and by this 
precaution infected lice may be immobilized. 

Delousing must be thorough. The hair of axillae, pubes, and any other 
parts covered with hair such as abdomen, chest and limbs must be shaved, 
and in men the hair of the head is cropped. The eyebrows and eyelashes 
should be carefully examined for lice. (After delousing an infested person 
the attendants strip, bath and put on clean clothing. Their infested cloth- 
ing is disinfected and disinfested. 

Recently, a synthetic preparation known as D.D.T. is employed both as 
a powder and in liquid form. It destroys insects at all stages of develop- 
ment and was successfully employed in preventing an epidemic of typhus 
fever in Naples in 1943. It is more than likely that the use of D.D.T will 
revolutionize and simplify the prophylactic measures recommended in 
louse-borne infections. 

EPIDEMIC TYPHtrs FEVER (Ja« /ever) 

Typhus fever is conveyed from sick to healthy persons by the bodty 
louse, and also probably by the head louse. This disease has been epidcknic 

450 



4^0 LOUSE-BORNE DISEASES 

throughout centuries, and tends to spread in conditions of famine and 
where there is overcrowding and lack of sanitation. It is due to one of the 
Rickettsia bodies — Rickettsia prowazeki, named after Drs. Rickets and von 
Prowazek. Definite precautions are now being taken to prevent, and/or 
deal with an outbreEik should it occur in this country during the present 
war. 

The course of the disease is 6f about 3 weeks’ duration. The incu- 
bation period is from 8 to 1 2 days. The onset is sudden with severe headache 
and general pains, marked prostration and characteristic mental torpor. 
The rash appears between the 3rd and 6th days as red papules over chest, 
abdomen and trunk, and spreads to the limbs. On fading a staining is left. 
In some cases there is desquamation. The rash may be haemorrhagic. 
The tongue is furred. The temperature is high — 104^ to 106® F. or more; 
tJiis persists for about 12 days and declines rapidly. The pulse rate is also 
increased, but not proportionate with the degree of temperature. 

There are two characteristic features: 

(1) The blood pressure is markedly low^ so low that the circulation to the 
extremities may be seriously affected and give cause to gangrene. 

(2) Mental torpor is always present and it may progress to one of wild 
delirium. 

Complications. The commonest are bronchitis and epistaxis. There is 
danger of heart failure. Toxaemia is grave. The possibility of gangrene has 
been mentioned. 

Treatment and nursing. Cardiac stimulants and regular doses of 
adrenalin are given to help to maintain the blood pressure. The diet needs 
to be very nourishing and should be supplemented by glucose. The disease 
is serious, the patient requires good nursing can and the nurse can do much 
by careful handling and frequent feeding to bring about a favourable 
termination. In addition, the mouth should be kept clean, the tongue moist, 
the skin free from pressure, the bowels acting regularly, and the urine 
should be me^ured and tested for albumin. Tepid or cold sponging will 
help reduce the temperature. 

Once the temperature declines the patient feels quickly better, but he 
must be made to avoid effort until his heart has regained strength and 
the blood pressure has improved. 


EPIDEMIC RELAPSING FEVER 

Louse-bome Relapsing fever is conveyed by lice, as the name implies 
to distinguish it from the tick-borne relapsing fevers of the tropics. It is a 
disease which spreads when the population is cold, starved and debilitated 
and was formerly known as famine fever ^ typhus (see p. 459) being desig- 
nated The European type of relapsing fever is due to the Spiro* 

chaeta recurreniisy it is conveyed by body and head lice and possibly also by 
the bed bug. The incubation period is two to twelve days. 

Symptoms. The onset is sudden with rigor and rise of temperature to 
104*^ F. or more, headache and general pains. The pulse is rapid. The 
t^perature remains high for about 6 d^tys, during tnis time the patient 
is restless and thirsty, refuses food and may vomit. When the toatiTOrature 
falls he wants to cat, is sometimes ravenously hungry, and may feel weE 



EPIDEMIC RELAPSING FEVER 46 1 

enough to get up, whilst in other cases he may be so prostrated by the 
period of high fever that he is in danger of collapse. 

The chart is characteristic. After a week of fever tWe is a fever-free period of 
about a week or so, then up swings the temperature again and all the 
symptoms are repeated. After 4 or 5 days it falk rapidly once again until 
the next relapse occurs. In untreat^ cases this sequence is repeated until 
the fever wears itself out. The disease may be complicated by jaundice, 
diarrhoea, haematuria and pneumonia. 

Treatment and nursing. General nursing measures are necessary; 
high fever may be reduced by cold spongings; perspiration at the crisis 
must be removed by hot sponging, drying and changing the clothing. 
Symptoms are treated as they arise, plenty of duids containing glucose 
should be given during the bouts of fever, and nourishing diet during the 
fever-free periods; care must be taken not to set up diarrhoea by injudi- 
cious feeding as the patient being hungry will eat anything and every- 
thing. 

Arsenic is specific and an intravenous injection of neosalvarsan at the 
outset usually proves effective. The duration of the disease depends upon 
the early administration of neosalvarsan and the length of convalescence 
depends on the general condition of the patient. Those who are physically 
fit recover rapidly, but those already debilitated by starvation, such as 
those living under conditions which pertain in the occupied countries 
today, will find convalescence long and tiresome and need good nursing 
care until recovery is complete. 

Prophylaxis is the same as for typhus. 

TRENCH FEVER 

Trench fever is so-called because it occurred amongst the men in the 
trenches during the war of 1914-18. It is a disease due to one of the 
Rickettsia bodies— quintana. Infection is conveyed by lice — not, it is 
thought, by the bite of the louse but by the excrement being rubbed into 
the skin in scratching. The incubation period is from 10 to 30 days. 

Symptoms. The onset is characterized by headache, and general 
pains, particularly of the shins, the pain is worse at night and prevents 
sleep. The spleen is enlarged. In a number of cases there is a papular red 
rash on the trunk. The temperature may be intermittent, resembling 
relapsing fever to some extent or low fever may persist for weeks. The 
patient gets thin, he looks ill and anxious and becomes anaemic; he is 
very depressed. 

Treatment lies in relieving the symptoms. Some analgesic such as 
aspirin is given for the aches and pains. Hot stupes may help. Rest, 
tonics, and a good nourishing diet are necessary to relieve the state of 
debility to which cases of trench fever are liable. 

Prophylaxis is the same as for typhus. 



Chapter 30 

The Nursing Care of Infectious Diseases 
(Fever Xursing) 

Introduction — Methods of isolation — General nursing care — Note on cross-infection^ 
return case and the administration of quarantine — Diphtheria — Scarlet fever — 
Measles — Rubella — Whooping cough— Mumps — Smallpox — Chickenpox — 

Vaccinia 

(See also Chapter 28 and for cerebrospinal fever see p. 41 j) 
INFECTIOUS DISEASE 

T he importance of fever nursing cannot be overestimated. Cases of 
infectious disease arise in the wards of a general hospital from time 
to time, and in the children’s wards with comparative frequency. 
These diseases are common to all ages and many of them are illnesses of a 
serious character. An infectious disease is a primary condition, but it may 
be accompanied by very serious complications and followed by sequelae 
which may be, and often are, far-reaching in their effects on the health of 
the community. 

Many of the medical and surgical conditions which are met with in the 
outpatient department and the wards of a general hospital arc due to in- 
fectious disease. Scarlet fever and measles may be followed by middle car 
disease, which may persist for years, and the organic lesions — cardiac and 
renal — ^which may be left after scarlet fever are very well recognized. 

GENERAL MANAGEMENT OF INFECTIOUS OASES 

In her care of a patient suffering from an infectious disease the nurse is 
called upon to consider the nursing of the sick person, the possible spread 
of infection to others and the prevention of infection to herself. In the fol- 
lowing notes the provision of ventilation is considered and in addition the 
application of rest, administration of diet, care of the patient’s toilet and 
methods of isolation. 

The provision of good ventilation. Fresh air is very necessary; the 
more air available, the smaller is the risk of spreading infection. If possible 
each bed should be allowed i ,200 cubic feet of space. Provision should be 
made to prevent the rising of dust when sweeping; dust collected around 
the area of an isolated bed should be picked up at the foot of the bed and 
not swept down the ward. The importance of careful wet dusting of fur- 
niture and walls in a ward or room in which cases of infectious disease arc 
nursed cannot be overestimated. 

The diet during the febrile stage should be limited to fluids; the patient 
must be given plenty of water and watery drinks, and these should be 
pressed upon him. A thirsty patient is usually willing to drink, but a 
patient with a bad sore throat may need a good deal of persuasion to take 
the fluid he needs. In most cases of infectious disease the febrile stage is 

462 



GENERAL MANAGEMENT OF INFECTIOUS CASES 463 

coraparativdy short, unless complications occur; but, when it is prolonged, 
means must be found of giving plenty of nourishment in whatever form 
the patient can be persuaded to take it. 

Rest. During the period of acute illness it is essential for the patient to 
be at rest in btd, and the ward should be quiet. The period of rest that is 
needed varies with each disease but, generally speaking, a patient should 
be kept in bed until all danger of serious complications is over. Gases of 
measles are liable to develop pneumonia up to the fourteenth day, and 
cases of scarlet fever are not out of danger of nephritis until after the nine- 
teenth day. 

The care of the toilet is important in all cases of infectious disease. The 
patient should be bathed night and morning; the mouth must be kept 
clean; the nose, eyes and ears will need careful treatment in special cases; 
and he should be washed locally after the use of the bedpan. 

In otitis media and otorrhoea the auditory canal should be cleansed 
with peroxide of hydrogen followed by the instillation of glycerine and 
carbolic 5 per cent. The carbolic relieves pain and the glycerine is hygro- 
scopic. In cleansing the ear padded ear sticlB, carefully dressed with a fairly 
large pad of cotton wool at the end, should be used. These may safely be 
inserted from J to J of an inch, if the canal is first straightened by pulling 
the pinna gently upwards and backwards. The frequency of the treatment 
depends on the amount of discharge, of which the canal should be kept 
free; the latter should not be plugged with cotton wool but left clear, and 
the ear may be covered by a pad of sterile wool lightly bandaged on. The 
pinna should be kept clean and free of discharge, as if this is neglected 
chronic eczema may ensue. 

The nose. When rhinorrhoea is present the nose should be kept quite 
clean and dry, the margins of the nostrils being lubricated with white vase- 
line or liquid paraffin, or excoriation will result. 

The eye. Whenever there is any conjunctivitis, however slight, the eyes 
should be bathed with a weak solution of boracic or saline; and ihey must 
be protected from exposure to light when photophobia is present. The 
presence of an exudate necessitates lubrication of the margins of the lids 
with yellow oxide of mercury ointment 2 per cent, at night, and the removal 
of any crusts by bathing with a solution of borax and water as often as 
necessary to keep the margins of the eyelids free. 

METHODS OF ISOLATION EMPLOYED IN FEVER 
HOSPITALS 

Pavilion system. In this plan separate blocks are provided for the care 
of each type of disease, some being set apart for measles, others for diph- 
theria and so on. Nurses working in these wards usually wear an overall 
over their dress when on duty and they share a house or home with other 
nurses, but when transferred from one block, to nurse another disease in a 
different block, they disinfect themselves by having an antiseptic bath, 
washing their hair and putting on fresh clothing. 

Cubicle system. Each patient has a separate cubicle and, if the system 
is strictly adhered to, every article for the patient’s use is kept in his cubicle. 
The doctor and nurse put on gowns when entering, and remove these, and 



464 CARE OF INFECTIOUS DISEASES 

wash their hands carefully before leaving the cubicle. Articles used for the 
patient are disinfected and replaced in his cubicle. 

Barrier nursing is a system which was instituted when physicians 
began to consider that disease germs are not carried by the air, but on 
particles in the air and on utensils and articles used by, and persons who 
have been in contact with, infected persons and places. This sptem was 
first practised extensively in England at Plaistow by the late Dr. Biernacki. 
He isolated one or two patients, amongst others, not so isolated, in a 
general ward. A slight distinguishing mark was used to indicate the beds 
isolated and all the utensils and articles likely to be required by a patient 
were kept on or in a specially devised locker at his bedside. Two gowns 
hung by the bed for the use of doctor and nurse, and arrangements for 
washing the hands after handling the patient or any of his utensils were 
provided at each bedside. 

Bed isolation was the next advance. This system was extensively used 
by Dr. Rundle at Fazakerley in 1918. This differed from barrier nursing 
in that it was considered that the majority of articles needed by a patient 
could be used in common with other patients, provided they were properly 
sterilized or disinfected after use. Gowns were provided at each isolated 
bed, and arrangements for washing the hands, preferably under running 
water, were supplied. All feeding utensils may be used in common pro- 
vided that they are rinsed and washed in a sink kept specially for this pur- 
pose after use and then boiled for twenty minutes in a sterilizer in the ward 
kitchen. It is important to note that all feeding utensils handled by an in- 
fected patient, including the dinner knives, must be boiled. Sanitary uten- 
sils can be washed and disinfected or boded after use. 

application of method. Before approaching the bed to perform any treat- 
ment of the patient, the nurse should roll her dress sleeves up well above 
the elbow, and put on the overall which is hanging at the bedside — this is 
made to fasten at the back of the neck by a button or tape, the waist being 
secured by a tape. 

To put on an isolation overall it is important to avoid contamination of the 
dress or apron; therefore remove the gown from the peg by taking hold 
of the loop by which it hangs, hold it by the neck and put first one arm and 
then the other into the armholes, fasten the button and tie the tape. To 
remove it, unfasten the overall, grasp the outer side of the margin of the 
sleeves and pull off, drawing the hands through the sleeves gently to avoid 
contaminating the interior if possible; then, holding the overall at the 
shoulders, loosely so that the outer contaminated side is folded inside, re- 
turn it to the peg and as it hangs the inner uncontaminated side lies outer- 
most. This is important, as the other nurses in the ward may inadvertently 
touch the gown as it hangs, and moreover the nurse will handle this side in 
putting the overall on, thus rendering contamination of her dress and 
apron less likely to occur. 

The nurse should remove the overall before washing her hands. She should not 
leave the bedside wearing the overall, except to remove and empty used 
sanitary utensils, in which case any doors through which she may have to 
pass should be opened for her so that they arc not handled by the nurse 
who is infected. 

The personal bed laundry from an infisetious case which is being nursed 
in a general ward should be disinfected before being sent to the laundry. 



METHODS OF ISOLATION 465 

This may be done either by steam disinfection, or by soaking the linen in 
Some standard disinfectant solution, such as carbolic lotion 1/40, for two 
hours. It is then wrung out, put into a separate receptacle and labelled 
‘Wet, disinfected laund^’. 

Excreta. The nurse empties the utensils wearing her overall, and then 
places them in a bath of disinfectant in which they are to lie, either to 
render them no longer infectious or until they are required again. Excreta 
from typhoid patients must be disinfected before it is disposed of, and this 
is done by receiving the excreta into a small quantity of disinfectant solu- 
tion, such as 1/40 carbolic, covering it with 5-10 ounces of the lotion and 
allowing it to stand in an air cupboard, provided the receptacle is covered 
with a cloth wet with disinfectant, for from tw’o to four hours before being 
disposed of. 

Visitors. Whereas it would be ideal if one could arrange for visitors to 
view their infectious relatives from the ward door only, this is not always 
possible. When visitors are admitted, the nature of the infection should be 
explained to them and they should be advised not to touch the patient or 
his bed. They should wear an isolation gown with long sleeves to the wrists, 
and if infection is conveyed by the nose and mouth they should also wear a 
mask. On removing the gown, the face as well as the hands should be 
washed before leaving the ward premises. 

The disinfection of a patient before discharge. The evening before 
a patient is discharged he should have a bath, and his hair should be 
washed. He should then be put into a clean bed if possible. All the articles 
which have been used for him will then be steriliz^, and it is very impor- 
tant to sec that such articles as the soap, the washcloth and toothbrush arc 
burnt. The bed and bedding and floor should be dealt with as described 
on p. 469. 

Relapse is comparatively common in some of the infectious diseases: 
the patient, when the symptoms of the first attack have subsided, entering 
upon a second course of the disease. This is usually less severe than the 
first attack; but, because the patient may be very anaemic and debilitated 
as a result of the first — particularly when relapse occurs after a long illness, 
such as typhoid fever — he may then be more seriously ill than during the 
first attack, because his powers of resistance are lower. 

Return Case. This term is used to describe a case of infectious disease 
which occurs in a house or locality to which a patient has recently returned 
after hospital treatment for the same disease. For example, a patient who 
has had, and recovered from, scarlet fever returns home; within the incu- 
bation period — that is, within 10 days of his return — another person living 
in the same house contracts the disease and is taken to hospital. This is a 
return case, the infection being due, almost undoubtedly, to the fact that the 
patient who returned home was not free from infection. 

Quarantine is the period of time it is necessary to isolate persons who 
have been exposed to an infectious disease, in order to prevent their con- 
veying this d^ase to other persons, should it prove that they themselves 
have contracted it. They are therefore kept in quarantine for a days longer 
than the known maximum of the incubation period. Fot example, the in- 
cubation period of measles being from 7 to 14 days, the period of quaran- 
tine would in this case be reckoned as 16 days. 



466 CARE OF INFEOTIOU8 DISEASES 

A nurse is expected to know the incubation period of each disease, as 
she may have the responsibility of putting a wand into quarantine, should 
a case of infectious disease occur. 

This means that the ward will be closed to visitors and new patients — ^in 
the case of measles, for 16 days. During this time no patient is discharged, 
or moved from the ward for any purpose; he may not be operated on, if 
this means taking him to the theatre, nor may he be taken to any other 
department in the hospital. 

Moreover, during the period of quarantine, a careful watch must be 
kept for the earliest signs of the disease which may break out. When these 
are seen the patient is isolated or removed to a block or unit where infec- 
tious diseases are nursed, and the period of quarantine will have to bemn 
again whenever any fresh case occurs. The only way to ensure that this 
should not be necessary would be to nurse every patient in the ward which 
is in quarantine under the principles of bed isolation. Each patient being 
isolated from the other, one would not then infect another should a case 
occur. For details of the arrangements for bed isolation sec p. 464. 

CROSS INFECTION 
{See also Methods of Isolation, p. 463.) 

The term Cross Infection has been in use for many years to describe the 
contraction of an infectious disease or infection whilst a patient was 
suffering from another infectious disease. It has recently been extended 
to cover any infection acquired under hospital conditions. 

Sources of cross infection in ^spital. Any evident infectious or infective case ; 
any infective case which may not have been diagnosed; any infectious 
case which, dming the incubation period (before the disease is diagnosed), 
is infectious, measles, for example. A carrier of disease. 

Modes of convening infection and control of infection. The skin, hair and nails 
of patients, staff, and hospital visitors are likely to be contaminated with 
infective secretions, excretions, discharges, and with dust from the floor, 
personal clothing and bedclothing. It is in order to avoid carrying infec- 
tion in this way that nurses are provided with facilities for frequent and 
careful hand washing, and with lotion or cream for the care of the skin. 
The nurse’s cap is not a badge of oflftce, it is intended to cover the hair in 
order to protect it from contamination and from becoming a source of 
infection. The hair should be pinned up under the cap. The nails should 
be kept short and nail varnish should not be used. Wrist watches should 
not be worn when on duty. 

Clothing. The personal clothing of patients becomes contaminated and 
that of nurses may do so. The handkerchiefs of those who harbour 
haemolytic streptococci in the nose and throat are serious sources of 
infection. 

Bedclothing. When infection is disseminated, in particular from the 
respiratory tract and the skin, and to a lesser extent from gastro-intestinal 
infections and wounds, the bedclothing is heavily contaminated. Every 
possible precaution should be taken to handle bedclothes and pillows 
cjffcfully so that dust is not raised (see also cleaning, below). 

Leamdiy. SoUed linen is contaminated by secretions, excretions, dis* 
charges and dust. Very great care should be taken when handling it. 
Collection at the bedside should be into soiled linen canvas bags on wheeled 



GROSS INFECTION 467 

iimnes. The bag should be sent to the laundry where it will be sorted 
axKi counted by porters or the laundry staff. Soiled linen should not be 
handled by nurses as this causes serious contamination of their dress and 
they thus become sources of infection to others. In certain cases of 
infectious disease soiled linen requires disinfection before it is laundered. 
Certain articles, such as handkerchiefi and pillow cases, from tuberculous 
patients should be boiled before they are washed. Infant’s napkins should 
not be dealt with by nurses, they should be put into disinfectant fluid and 
sent to the laundry where they will be separately washed and they should 
always be boiled. 

Furniture and Utensils. All articles used in a ward are contaminated. 
AH ward furniture should be kept clean. All articles and utensils used 
should be sterilized between use. This necessitates having adequate equip- 
ment, which is a point that requires attention. 

Food and milk grow bacteria readily especially when not properly stored. 
All articles of food should be covered and stored in a cool place. 

Flies arc a serious source of spread of infection. Flics and their breeding 
places should be destroyed. 

Toys, books and papers. Only washable toys should be provided. These 
should be tied to the head of the bed and the lead should not be long 
enough to allow the toys to fall on to the floor. Books and papers should 
not 1^ passed from bed to bed. 

Ward Cleaning. Bedmaking and sweeping raise dust and it has been 
shown that the air of the wards after these processes has a high bacterial 
content. The experience gained in the plastic surgical units has demon- 
strated the effective control obtained in this matter by the oiling of 
blankets and floorboards. But this measure is not always possible and a 
good deal can be accomplished by the use of scientific methods of sweeping 
and cleaning. 

Dry sweeping should never be permitted. Damp sweeping and damp 
dusting are essential. Brooms, brushes and dusters should soaked in 
disinfectant after use, then weishcd and dried. Nurses should not do the 
domestic work of a ward if they are responsible for patients’ treatments 
and surgical dressings. 

Carriers of Disease. A ‘ convalescent carrier ’ is a person who is convales- 
cent from an infectious disease or infection. A ‘healthy carrier’ is a 
person who harbours infectious organisms in his tissues in sufficient viru- 
lence to cause disease in others without himself falling a victim. These 
carriers arc dangerous because they are not recognized and may pass un- 
suspected for a long time. Their danger can only be determined by bac- 
teriological examination. 

Both the segregation and the treatment of carriers has to be considered. 
Persons who carry haemolytic streptococci in the throat should be sepa- 
rated from those liable to infection such as obstetric and smgical cases. 
Carriers of diphtheria may be successfully tieated by having the tonsils 
and adenoids removed. But when the nasal mucous membrane is the 
source of infection local application of antiseptics may be tried. 

In addition the general health of the person who is acting as carrier 
should be attended to and any measures which will improve the condition 
adopted. During this period of treatment any test available will be made, 
from time to time, in order to ascertain when the individual gives a 
negative Reaction to any test employed. 



468 CARE OF INFECTIOUS DISEASES 

Control of droplet infection. Moist infective particles from the 
nose and mouth may contaminate an object or surface directly by falling 
upon it; and less directly by being carried on particles in the air as in 
dust. 

The patient who is suffering from an infection of the respiratory tract 
should be taught to cover his nose and mouth when coughing and to 
avoid spraying moisture in speaking and laughing. 

The nurse should develop a regime when nursing patients suffering from 
respiratory infections. She should not get her face near to the patient’s 
face, turn his head to one side when performing any treatments for him, 
visualize the range of droplet infection and avoid directly facing the 
patient. Face masks should be worn so that she docs not spread infection 
from her nose and mouth when attending to babies and infants, when 
preparing feeds for infants, when preparing and performing surgical 
dressings (see p. 651), and when attending to the nose and throat of a 
patient. 

Face masks must cover the nose and mouth, they must be of adequate 
thickness, they should be placed in disinfectant after use, and boiled and 
washed. If possible they should never be used a second time; if this is 
not possible then the inside of the mask should be clearly marked. 
Masks should not be kept in the pocket. 

Ventilation and bed spacing. Free and good ventilation will go a long way 
towards preventing droplet-bome infection. Wards should be thoroughly 
aired after bedmaking, sweeping and dusting. The windows should be 
open as much as possible. Thorough airing should precede closing down 
for the night. Blackout arrangements should not interfere with ventila- 
tion. If they do so then the lights should be extinguished and the wards 
aired thoroughly several times during the night. 

Bed spacing is important, and if droplet-borne infection is to be pre- 
vented the distance between beds should not be less than 8 feet. In 
maternity^ units, infectious diseases hospitals and children’s wards the 
space should be not less than the 12 feet recommended by the Ministry 
of Health. The distance is calculated from bed centre to bed centre. 

THE NURSING OF AN INFECTIOUS CASE IN A 
PRIVATE HOUSE 

It is interesting to note that the majority of nurses to be found on the 
private nursing staffs of hospitals and institutions have been drawn from 
general hospitals and have had very little, if any, experience of infectious 
work, and yet the first case to which a nurse will be called may possibly be 
one of this nature. It behoves her therefore to consider very carefully what 
she will do in these circumstances. The relatives and everybody with whom 
she comes in contact will expect her to be a fount of infonnation and 
resource in the difficulty in which they find themselves placed. 

The choice of a room is important; if possible the aspect should be south- 
west, and the room should be well ht and ventilat^, A fireplace in the 
room is valuable, as by means of it waste food, dressings, letters, &c., can 
be destroyed. The room should be as far as possible from the living rooms, 
and near to a bathroom and w.c., and also near the nurse's bedroom. As 
little furniture as possible should be retained in the room and the walls 
should be equally bare. A bed will be nectary, one or two tables, a chair 



NURSING OF AN INFECTIOUS CASE 469 

or two, a small chest of drawers and some shelves on which feeding uten- 
sils, &c. can| be kept. The patient’s washing basin, toilet articles and sani- 
tary utensils should all be kept in the sickroom, and a pail in which the 
nurse can carry waste water, disinfected laundry, and so on, from the 
room. Near the door, either just outside or just inside, should be placed 
provision for the nurse and doctor to wash their hands. This provision 
should include a bowl of disinfectant solution and a nailbrush. Coats 
should be provided fqr the doctor and nurse, and for visitors in case of 
necessity. A sheet hung outside the door may be found to give the relatives 
confidence. In any case it acts as a reminder that the room is not to be 
entered and that its occupant is isolated. 

In the nursing management of this patient it is an important point that 
articles once in the room remain there and do not leave it — therefore, in 
receiving food from the kitchen the nurse might have a table just outside 
the door on which the utensils are placed, then having removed her gown 
and washed her hands she could transfer the food from the kitchen uten- 
sils to the patient’s utensils, without contaminating those from the kitchen. 

The nurse will do all the domestic work required in the patient’s bed- 
room. She will sweep and dust it, attend to the fireplace, wash up all the 
crockery in the room, carrying the waste water to the lavatory and empty- 
ing it as she would excreta. Unless excreta are a source of infection the 
nurse empties them into the w.c. pan without soiling the sides more than 
she can help. She pours some disinfectant round the sides of the basin 
afterwards and then pulls the plug. All discarded food and used swabs, 
&c. arc burnt in the fire in the room. The ashes from the fireplace, which 
the nurse attends to herself, she will collect in a piece of paper and trans- 
fer to the dustbin. The nurse will be responsible that infection is not con- 
veyed to the public through the medium of laundry. Soiled clothing from 
the patient’s bedroom, including doctors’ and nurses’ gowns, should be 
soaked in some disinfectant, such as carbolic acid, i /40, for several hours 
before it is dispatched. The laundress should be notified that she is to re- 
ceive wet disinfected laundry, and that proper precautions have been taken 
to prevent infection. 

Visitors. The same precautions will be taken regarding visitors as des- 
cribed on p. 465. It is always inadvisable to permit children to visit an 
infectious patient. 

Terminal disinfection. This is carried out as previously described 
(sec p. 465), the patient having his head washed, being bathed and put 
into a clean bed, and if possible into a clean fresh bedroom. 

The room he has occupied will then be available for disinfection. The 
bedding should all be sent to be steam disinfected, including any other 
heavy articles such as pillows or rugs he may have used. Personal clothing 
and bedclothes left in the room should be disinfected before going to the 
laundry. As a rule it is sufficient if the walb are swept and washed, the 
floor scrubbed, and all furniture washed with hot water and soap. All the 
utensib which have been used should be boiled, and all toilet accessories, 
if possible, burnt. In a few instances it is necessary to strip the wallpaper 
and subject the room to fumigation; but as a rule thb will be ordered by 
the doctor and attended to by the local sanitary authorities. 



470 


CARE OF INFECTIOUS DISEASES 


SPECIAL CARE REGARDING THE HEALTH OF A NURSE WHEN 
NURSING A CASE OF INFECTIOUS DISEASE 

The nurse has to realize that she may become infected, and then she is 
herself a source of infection to other people. It is for this reason she wears 
an overall when in the sickroom. She may move about the usual offices 
such as the lavatory, w.c. and her own bedroom in her nurse’s dress, but 
she should not go into the living rocan or the dining room or leave the 
house unless she is wearing her private dress. If she writes letters or does 
any sewing in the sickroom, these articles must be disinfected before they 
leave the room. She could disinfect them by boiling some formalin solu- 
tion I per cent, in a kettle in the room and holding the articles in the steam 
from this until they are thoroughly saturated. 

The nurse must maintain a high standard of general health, and keep 
herself fit. She must take her meals regularly, and if possible elsewhere 
than in the sickroom. It may not, however, always be possible to have a 
separate room at her disposal for this, but in that case she might have her 
meals in her own room. She should attend to minor ailments when these 
occur, and keep her skin free from abrasions and cracks. 

If the patient is a case of typhoid fever or any other case in which the 
excreta are known to be infectious, she should be very particular to wash 
not only her hands but her face b^ore eating, and to handle her food as 
little as possible. 

DIPHTHERIA 

Diphtheria is diagnosed by taking a swab from the affected area and 
discovering the causative organism which is a rod-shaped bacillus — the 
Klebs-Loefier bacillus or Coiynebacterium diphtheriae. 

Infection is direct or indirect, the disease being conveyed by milk and by 
carriers. The incubation period is from 2 to lo days, with an average incuba- 
tion of from 2 to 4 days. The fauces are the part most commonly affected, 
and the disease may spread to the larynx or the nose; any mucous mem- 
brane may be affected and diphtheria has been known to infect wounds. 

Faucial diphtheria. The onset is short, but more insidious thsm that of 
scarlet fever, and the throat in diphtheria may not be very sore. The 
patient suffers from malaise and may complain of headache, and there 
may be a slight rise of temperature. 

A gr^ish-yellow membrane forms on the fauces, and it is firmly adherent 
just as a slough would be. There is a little inflammation around the mem- 
branous area and the lymphatic glands beneath the jaw may be enlarged 
and tender. The temperature may remain elevated mr a few days, and in 
cases complicated by aepsis it is more marked. 

In diphtheria the organisms remain at the site of the leskm, pourii^ 
their toxins into the blood stream, and this results in marked toxaemia 
characterized by a soft pulse of low volume since the blood ptessure a low, 
while the patient lies listless and pale, obviously uninterestM by anything 
that is going on around him. 

It is in the complications may occur dining the course of diphtheria 

that the danger lies. Spread of infection downwards to the krynx and up- 
wards to the nose increases the severity of the disease, and the gravity of 
the toxaemia which is depressing the heart may result in cardiac failure', 



, DIPHTHERIA. 47I 

adenitis and otitis media may occur, and in the later days post-diphtheritic para- 
lysis is to be anticipated in all severe cases. 

The treatment is the early administration of the specific, antidiph- 
theritic serum. It is given in doses of from 5,000 to 25,000 units, and in 
some cases even larger doses are employed. The amount varies with the 
sevority of the illness, and not with the age of the patient, as even tiny 
childitm require doses as large as those administered to adults. 

In the routine nursing care the ^nger of cardiac failure must be ever borne in mind. 
The patient should be nursed flat, with one low pillow or without a pillow; 
he may not move to do anything for himself. He should never be allowed 
to become constipated but only the mildest of laxatives, such as liquid 
paraflin, may be employed, or small lubricating enemata. It is necessary 
to be constantly on the watch for signs of muscular paralysis; palatal para- 
lysis may be manifested by a slight catch on drinking, by difficulty in speak- 
ing certain words and by a slightly nasal intonation. 

Either ptosis or squint may be observed, or the patient may be seen to 
have lost eye accommodation, and he may sometimes be seen to push an 
article farther away from him when he wants to look at it. 

The slightest indication of paralysis suggests that the toxaemia has been 
severe and calls for greater and more prolonged rest, for fesir lest the 
dreaded complication of cardiac failure should arise. 

The rest necessary at the outset should be only gradually encroached 
upon as uncomplicated convalescence progresses. The patient may gradu- 
ally be elevated from the recumbent position and allowed to sit propped 
up, and at the end of two weeks he may be allowed some litde recreation 
in bed — reading, vsrriting or playing a game. 

Intubation and tracheotomy may be necessary for the relief of symiptoms in 
laryngeal diphtheria, and these procedures are described on pp. 729-3 1 . 

Schick’s test is used to determine the susceptibility of a person to 
diphtheria. A small quantity of diluted diphtheria toxin is injected intra- 
dermaUy into the skin, usu^ly of the forearm, while a control injection, 
consisting of the same quantity of the solution, heated to about 160® F. in 
order to destroy the toxins, is injected into the skin of the opposite fore- 
arm. The result may be as follows ; 

( 1 ) A positive reaction, which would indicate that the person was suscep- 
tible to diphtheria, would be an area of redness appearing within 48 hours 
and fading after a few days, to be followed by desquamation of Ac skin. 
The control arm remains unaffected. 

(2) In a negative reaction both arms would be imaffected. If both arms 
arc slightly and equally affected, the reaction would be due to serum pro- 
teins and not to the toxin. This is called a pseudo-reaction. 

(3) A combined reaction sometimes occurs, and this is manifested by a 
pseudo-reaction as described above on the control arm, with a true reac- 
tion as described in the first instance on the arm on which the test was 
employed. 

Artificial immunization of children should be encouraged. 

SCARLET PEYER 

Scarlet fever is a very acute infectious disease due to a haemolytic strep- 
tococcus — streptococcus scarkdinae. 



472 CARE OF INFECTIOUS DISEASES 

Infection is direct or indirect, and the disease is conveyed by milk and by 
carriers. The secretions are infectious and so is any exudate or discharge 
from the body cavities or from cracks or abrasions of the skin. The incuba- 
tion period is from i to 8 days, with an average of from 2 to 4 days. 

Symptoms. The onset is sudden, with headache, sore throat, vomiting 
and a rapidly rising temperature up to 103° or 104° F., and marked in- 
crease of pulse rate, 120 or over. In adults there may be an attack of 
shivering, and in children convulsions may occur. 

The tongue and the throat. The tongue is covered with a thick white fur 
and the throat is red and injected. On the second day red papillae show 
through this fur, giving the typical strawberry tongue. The tongue peels. 

The rash appears on tiu second day, covering the sides of the neck and chest 
and spreading over the trunk and limbs. The face is flushed and the cir- 
cumoral region characteristically pale. The rash is composed of minute 
points and is scarlet in colour; it is described as a punctate erythema, and 
lasts from a few hours to a few days, being followed by desquamation, skin 
rubbing off from the sides of the neck like powder; at the end of a week 
little pinhole breaches occur in the skin over the front of the trunk; later, 
the skin separates at the tips of the fingers, and then larger pieces of skin 
come off from the hands and feet. 

During the febrile stage the patient suffers from marked malaise, head- 
ache, loss of appetite, his urine is scanty and high coloured and constipa- 
tion is present. 

The complications of scarlet fever are adenitis, rhinitis, otitis media, ar- 
thritis, nephritis and endocarditis. 

Treatment. The specific treatment of scarlet fever cases is the adminis- 
tration of antiscarlatina serum, which is given in doses of from 10 to 20 c.c., 
intramuscularly and in the more severe cases into a vein. Sulphanilamidc 
preparations are at present being used with considerable success and prov- 
ing of value in preventing the incidence of complications. 

It is usual to keep the patient in bed for 2 1 days in order to avoid the 
complication of nephritis; he should be kept warm, and receive a liberal 
supply of fluid; and his urine should be tested daily for albumin. The 
symptoms are dealt with as they arise, complications are anticipated and 
treated should they occur. 

Dick’s test. This test is employed in order to determine the suscepti- 
bility of a person to scarlet fever. It is carried out by the intradermal in- 
jection of a small quantity of diluted scarlet fever toxin, in the way des- 
cribed in the case of the Schick test (see p. 471), a control area being 
similarly used. 

The result may be : 

(1) A positute reaction, shown as a patch of redness at the site of the in- 
jection, occurring approximately within 24 hours with no change on the 
control area. 

(2) A negative reaction shows no change on either area. In a pseudo-reaction 
slight inflammatory changes occur on both areas due to protein irritation. 

(3) In a combined reaction, as in the case of the Schick test, a pseudo- 
reaction occurs on the control arm and a true reaction on the test arm. 

Schultz-Gharlton’s test. The Schultz-Charlton reaction, which is 
sometimes described as the blanching test, is used as an aid to diagnosis in 



fOAtuusT rEvsR 473 

stiqMxted cases of Bcariet^j^ wiuch a rash is present A minute quan- 
tity dilute scarlet fever antitoxin is ityected intradermally where the 
raum » bright. A positm reaction would be denmnstrated by the blanching 
of au area of the rash around the site of injection, and the area blanched 
may be the Size of a tworshUKng piece. 

A noction need not necesuuily mean that the case is not one of 

Scarlet fever — it is in its positive reaction that this test is valuable. 

MEASLES 

Measles or tnorbilH is a highly infectious disease which is responsible for 
a large percentage of deatlu among infants and young children, and all 
nurses would realize that children must be protecct^ from this dread 
disease; not every child has measles and the idea in the minds of some 
membero of the lay public that a child had better have it and get it over 
is deplorable. A delicate child is very likely to develop broncho-pneumonia 
which is a serious and often fatal complication of measles. 

Infection. The disease is spread by direct and indirect means, and, as the 
iirfectivity is high, few persons escape if they are exposed to infection. The 
incubation period is from 7 to 14 days. 

Symptoms. The onset of measles is manifested by catarrh of the upper 
respiratory passages; there is sneezing, running at the nose (coryza), 
■watery eyes, intolerance of light (photophobia) and a tendency to con- 
junctivitis. The patient is hoarse and has a short dry cough, due to an in- 
flammatory condition of the larynx which may spread down the bronchial 
tubes and give rise to bronchitis and broncho-pneumonia. 

A prodomal rash, which is sometimes the only rash present, occurs during 
the catarrhal stage. It is known as Koplik's spots, which are bluish-pearly- 
white spots seen on the buccal surface of the membrane of the mouth. 

The typical picture of a patient with measles is seen when the true rash ap- 
pears on the fourth day, beginning at the roots of the hair and behind 
the cars and spreading over the face, trunk and limbs. The eyelids are 
swollen and heavy, the patient is very miserable, the heaviness of his eye- 
lids is wearying and he is unable to tolerate any direct light upon his eyes. 

The characteristic rash of measles is macular; it appears in irregular 
patches which give a blotchy appearance to the skin. It lasts a or 3 days 
and then fades, leaving the sl^ slightly stained but the staining dis- 
appears after about a week. 

The temperature rises at the outset of the catarrhal stage, and then de- 
clines, to rise again when the rash appears, and eventua% decline as the 
rash fades. The pulse is increased in rate, but not markedly so; it is the 
increase in the rate of respiration which is characteristic of mesuiles, and 
this is diie to the inflammatory condition of the respiratory tract. The 
patient is restless, tossing about in bed, and sometimes delirious durinj^ 
the febrile stage. 

GompUcatlons. It is in the complications that the danger lies in 
measles. Some d^pree of laryngitis and kronchitis adll be present in most 
cmeAihroneho-prmmmia may arise. A little comunctioitis is invariably present, 
and a more serious degr^ may occur; commuker may ccHoaplicate meades, 
espodally in debilita^ subjects. Otftu media, enteritis and cancrum oris are 
other posdble complicatiems. 



474 tNnS43TtOt» filSBABBS 

Treatment. A Mrom is now obtainaUe which is tsdcea Sron cases who 
are convalescent hxun measlet, or from yooi^ adults who have had measles 
duri^ recent years, it is used, partly as a pioidiylactic measure, but more 
pardculaily to protect ddieate children who have been exposed to the 
disease and who may have entered the incubation period. Wheh given be* 
fore the seventh day, it usually prevents the attack aitc^therr wi^ givm 
after the seventh day, althou^ it is unable to {uevent the attack it wUl 
render it less severe. The dose is from 3 to 6 c.c. 

In the nursing care of measles the room should be warm, from 63° to 65° F., 
and it should be well ventilated, the patient being kept very warm in bed, 
which should not be &cing the light, and having ^ chest and back rubbed 
with warm camphorated oil at night, smd wearing a warm woollen vest. In 
cases where bronchial catarrh is marked, it may be necessary to moisten 
the air in the room by the use of a steam l^tle. The eyes should be bathed 
morning and evening, and oftener if there is any discdiarge. Care ^uld 
be taken to {nevent a child with measles from picldng his nose, rubbing his 
eyes or irritating any part of his body where ^e rash is thick. 

In most cases fluid diet will be given whilst there is a rise of tempera- 
ture; afterwards the diet should be light and very nourishing; the patient 
ought to stay in bed for a week after temf>erature has dedined, and be 
kept in a warm wcU-ventilatcd room for several days after he gets up; he 
may then be allowed out of doors during the wannest part of the day pro- 
vided he is warmly clad. 

RUBELLA 

Rubella, Rdthein or German measles, which is a much milder disease than 
measles, occurs most commonly after the ^e of ten and \mtil the end of 
adolescence. 

Itffection is by direct ccmtact with a patient, by means of injer^mi 
it is rarely conveyed by indirect means. The incubation period is from 5 to 
21 days (average 14-18 days). 

Symptoms. The onset of the disease may pass unnoticed, or it may be 
that the patient has slight malaise, sore throat and headache. The rash, 
which is often the first sign noticed, occurs on the second day of disease 
and is rose coloured; it begins in the same way as the rash of measles, 
behind the ears and at the roots of the hair, but it differs from measles 
in being a much finer rash. It fades in about 24 hours and leaves no 
'staining. 

The other symptoms are not severe. The conjunctiva of the eyes is slightly 
lifted, but the eyelids are not heavy as in measles. The thix^ is d%htly 
sore and there may be a short diy cough for a day or two; the temperaturo 
may rise to 99* or 100° F., but rarely higher than this. On/t si^, winch is 
characteristk^ Is enlazgemoit of the subocdpital group <» lymphatic 
glands, which lie above the nape of the neck, at the maiw where the 
occipital bone can be disdnctly felt. They may tte fdt as little hard roundish 
lumps, and it is worth rememberii^; that these glands are alio swdQen in 
die case of a head infected with lice. 

As a rule there are no complicatimis in rubelia, and ordtn^ nurring 
care is all that h necessary whmt the padeot is hi ^ ^ ^ ^ ^ ^ ^ ^ 



WBooroto eovo9 


475 


WHQOFINO €OUGH 

Whooping ccni|^ or p»tut^ is an infectious disease which usually at-' 
tew cbwiren- It is caused hy the Bordet-Gengou badllus or haemophUus per- 
tussis. 

l^ecthn may be direct or less often indirect. It is most usually spread by 
dr(il^ infection or iidection by means of very recently uKd feeding utennls, 
h a n d h e r chieft, and articles me child may nave had in his mourn, such as 
a pendi^ whidi will be covered with moist infective particles. The disesw 
is infective from the moment the catarrhal stage begins, and the incuhatum 
period is from 6 to i8 days. 

Whooping cough is divided into the catarrhal and the spasmodic stages, 
and the stage of convalescence. The cutarrhal stage is manuested by a short 
dry cough, coryza and bronchitis. There may be a slight rise in tempera- 
ture, die child’s sleep is disturbed by coughing, and at the end of two 
weeks the typical paroxysms of whooping cough will usually be present. 

Paroxysms of coughing may occur only once or twice in 24 hours, or 
they may occur fre(|uenuy about every hour, though this is 1 ^ usual. A 
typud attack of coughing begins with several short coughs following one an- 
other so rapidly t^t diere is no time for the child to inspire. A forcible in- 
drawing of air then occurs, which produces the characteristic whoop. The 
attack may be repeated, the child sits up in his cot, clings to the side of it, 
tears stream from his eyes, mucus runs from his nose and mouth and his 
tongue is protruded against his lower teeth. The child’s face becomes 
deeply cyanosed and may become oedonatous; he may pass urine and 
faeces involimtarily, epistaxis may occur or bleeding into die conjimcdva 
or into the tissues around the eye. In adults there may be cerebral hae- 
morrhage. Rupture of the pleura may occur, causing a spontaneous pneu- 
mothorax. The attack of whooping may end in vomiting. The child falls 
back very exhausted after a severe paroxysm. 

Paroxysms occur with greatest frequency during the night, when whoop- 
ing cough is always at its worst and, as this is when die first whoop is 
he^, in a suspected case the night nurse should be particularly obser- 
vanL The attach of coughing continue for several weexs, and in a case of 
moderate severity abatement may be expected after 6 weeks from the 
commencement of the illness. Inmrovemcnt is fairly rapid when convales- 
cence beg^, and the child quickly recovers the ground he has lost. 

GompUcatloiui. LfOryngiUs and brmchitis occur in most severe casm, but 
broncho-pneumonia is the complication which is most dreaded, since it is as 
serious in its effect with whooping cough as it is with mearies, and is the 
cause of death to many children. En^ysemOf asOana and pubnonmy itAer- 
cuhsis may be sequelae of whooping cough. 

Apart from the conmlications already mentioned, a large group of 
conditKKDs may arise man mechan i cal causes. Prolife <f rttUm t^y 
occur, and umbUical hernia may be caused by increase in intra-abdominal 
tension during a parincysmdTooughii^;. A may be produced 

by the sawing action of the ttmgue against the lower incisors when the 
toi^pse u protruded durmg coughing. Qmmlsions may occur duimg, or 
at the end of, a paroxysm. Emamiim due to wasting df the tissues is 
present in oases wdiape vomitiag invariably fidlows fr^uent attacks of 
couflhhtif. 



476 GARB or iWl^OltOtJS DUBASSS 

Treatment. Vaccine treaimetU is employed vddx socxess in many cases. 
Bdhdmma is used to reduce the sfKum m tm passages. IsoleAion 

is necessary from the conunencemeht of the catanii^ siage, a^ it should 
be continued until this has abated^ and in most cases thitil^ t^^ if 

no longer heard. This point has to be considei^ individiiaily i^th evei^y 
case, as some children with whoring cou^h may^ nevtar whoop, while 
others may develop a habit of whboping wmch is difficult tp break. 

The nursing care of a child with -Mdiooping cough is very important. The 
room should be waim and the child kqpt covered because of the ten- 
dency to develop broncho-pneumonia. It is usual tokeep thertiiil^ ^ 
during the cataithal stage, but later he may be allowed up. He should live 
in a w^-ventilated room and may be taken out during the ivannest parts 
of the day, provided he is properly wrapped up and does not get cold. The 
chest shbiild be rubbed, back and front, with warm camphorated oil at 
night. Stmport of the child is essential during an attack of coughhtgj and 
a tiny infant should be lifted and supported, as he needs to be helped to 
get the mucus and expectoration from his mouth. An older child should 
be trained to support himself, and to use a bowl for his sputum and vomit, 
All secretion and vomit, as it is infectious, should be disposed of as quickly 
as f>ossible. A binder round the abdomen will help to prevent an umbilical 
hernia, and the child should never be allowed to have an attack of cough- 
ing while sitting on a chamber, as this porition would predispose to pro- 
lapse of rectum. 

Feeding is very important, and diluted milk and glucose drinks should 
be given during the febrile and catarrhal stage. Subsequently the diet 
should be noiuishing and easily digested. A child who vomits after fre- 
quent attacks of coughing will become very wasted unless the precaution 
of feeding him immediatriy after an attack is taken. The vomiting induced 
by cougUng is not necessarily accompanied by nausea or by any disin- 
clination for food; it is a mechanical result of a bad attack of coughing. 

A child in whooping cough may be so fatigued and disinclined for occr- 
tion that he will not want to take his food, but he must be encouraged 
and coaxed, and even spoiled a little, and may be given anything he will 
take. 

MUMPS 

Mumps or specific parotitis is an infectious disease characterized by swell- 
ing of the salivary glands, which is most noticeable in the parotid, because 
of its position in front of and below the ear. It occurs in adolescence but 
is rardy met with in infancy. 

Ji^ecHon is usually direct, from contact with a patient, but indirect in- 
fection can also occur. Incubation period, la to 26 ^ys. 

Symptoma- The onset of the disease is accompanied by vs^ue symp- 
toms of malmsc, and chars^merized after a day or two by the typical swalf 
ing of the parotid j^and, usually on one side, the other side beginning to 
sti^ three or four days later. The skin over the swollen glands is tender, 
and there is difficulty in t^pening the mouth; the secretion of saliw causes 
pmn^ which woiild be accentuated on any stixnulation, and ibr tffis Tcmam 
acid £bids such ar lemonade, which tesid to inertose seffivatiba, are contra* 
indicated. When both sides are very swollen great discomfort is caqMT- 
ienced, and this may be accompanu^ by a slight rise in tonperature^ ^ 



STOMW' ■ 477 

may comi^icate mumps 

m ikdolescents and smults; sometimes occurs in males and 
mid 0S!(»^ in females. > 

Pancteetitis, which is very rare, is serious and accompanied by coUdty 
abdominal pain. 

Otiha* eompH^tiohs iiidude stipulation of the iffectei salivary ^ands, 
otitis media, deafness, aidhriHs (^ merttngitis. 

Treatment. The patient is isolated and kept in bed until the swelling of 
the glands has subsided and the teitnperature, if any, abated; 10-14 days 
in is the average time necessary. Keeping a patient in bed during this 
period should prevent the appearance of the metastatic sweilings men- 
tioned above. 

Feeding is a little diflSicult; the patient can usually swallow if he can get 
the food into his mouth; he may have any food he can take but articles of 
diet likely to stimulate the flow of saliva should be omitted, and it is cruel 
to allow the patient to see or smell such things as oranges. The mouth 
should be kept clean and the glands wrapped in hot wool whilst they are 
tender. Any local application should be light as the least touch causes 
acute pain during the inflammatory stage. Ordinary routine nursing 
measures are all that will be required. The patient should be isolated for 
three weeks, and for one full week after the swelling has subsided. 

OHICKENPOX 

Chickenpox, or varicella, which is a most highly infectious disease, is one 
of the two examples in which the rash appears in successive crops — the 
other exanqde being typhoid fever. 

Infection is direct or indirect, and the disease is infectious irom the com- 
mencement of the illness, before the rash appears, until the last scab 
separates. The incubation period is from 10 to 21 days, with an average of 
14-18 days. Infection may also follow contact with a case of herpes zoster 
(seep. 507). 

Symptoms. The mstt may be so slight as to pass unnoticed, and the 
rash, as it appears after 24 hours, is often the first sign observed. The rash 
of idticker^x is vesicular, each vesicle containing inflammatory exudate, 
and when the vesicles first appear they are bright and shining, but after a 
few hours lose this shimmering effect and become dull. The rash appears 
first on the body, inside the mouth and on the scalp. In a day or two some 
lesitms of die rash will be seen to have become slighdy purulent, others 
have dried and scaled off; the purulent ones will form scabs, which will 
separate Isder. As the rash spreads, most of the body will be covered, and. 
it is also seen on the face. "■ 

Crops cd* die rash appear daily for several days, so that it is quite usual 
to see dear vesicles, vesides filled with purulent fluid, dried vesides scaling 
off and scabs— all on the same area of skin. 

The temperature may be raised a little, but this depends on the density 
of the rash and the amount of pus present. The rash is ii^tadng and the 
pati«it is indmed to rub and scratch the irritable area, and this causes 
the scabs to be khpdtcd bflf, delay^^ and may re^t m string. 

Tiwfltmeat^ The parimu h kept in bed for the first wedt or two, and 
ordinsuy nuiring^^m be necessary; in addition the precaution 



478 CARS or nmotioos mssAiRs 

of hawing notHMtatiiig dodinng hiat to the ddtt 

tihe rash is very irritable bath^ vwith welJc adbdtic lotk>n, or 

with an astringent powder and applying an ointment ctnitaining a mUd 

antisqjtic may give rdief. 

Complicatioaa are rare; in debilihsted chUdrm may 

develop, and impetigo may arise aS a secondary infection. 

SMALLPOX 

Smallpox or variola is an acute very highly infectious disease, and as it is 
very likely to be confused with chickenpox a nurse should know how these 
diseases differ. 

It^ection is direct and indirect. One attack gives immunity for life, and 
it is considered that vaccination in infancy, repeated at the age of I2 years, 
will give complete immunity in meat cases, while in others these precau- 
tions will considerably modify the attack should the disease be contracted. 
The incubation period is from 10-14 days, with an average of 12 days. If a 
person is expceed to infection, vaccination should be performed; within 
the first 2 or 3 days it will prevent the attack, and up to the sixth day it 
will afford some degree of protection. 

Symptoms. The onset of smallpox could never po»ibly be confused with 
chickenpox, because in smallpox the patient is very ill, suffers from head- 
ache, pains in the back and limbs, vomits, runs a high temperature and is 
very seriously prostrated. This continues for 2 or 3 days, arid then the rash 
appears. Unlike the rash of chickenpox, that of smallpox appears in stages. 
A papular eruption appears on the face, hands and foet on die third day 
of disease, whereas in chickenpox the rash appears first on the trunk and 
upper parts of the limbs and is centripetal in distribution, while that of 
smallpox, apjpearing on the face, hands, forearms and feet, is centrifugal. 

Another difference is that in chickenpox the papular stage is so short 
that it is usually not noticed, whilst in smallpox the papular eruption 
which appears on the third day persists until the fifth or sixth day, when 
the papules becomes vesicles; these remain until the eigbUi to tenth day 
and then become pustular, ^er the twdUTth day the puttules begin to dry 
up and form scala. 

In chickenpiox the skin is clear around the rash, Imt in smallpox there 
is a sutroundii^ area of induration. 

The lesions in smallpox are round, and lie embedded in die skin; in 
chickenpox die lesions are oval, and lie on the skin. If a vesicle in chicken- 
pox is pridied, it wp be seen to collapse; in smallpox, collapse will not 
occur, as eadi vesicle is bilocular. 

To recapitulate: the rash qf smallpox appears in stages: 

On the diird day— papules. 

On the sixth day — ^vesides. 

On the ninth day—^mstides. 

On the twdfth day— the rash b^;ias to ftmn scabs. 

The scabs have usually aS separated Wid^ about 6 wcdb. 

The ten^atme in smmpoxhm^ at the onset of the (hsduu^ but dd^finei 
when die tash first appears and then fhes again, oaice becotnh^; 
very high wfaoi the pustular stage begins^ as '^ is aeoompwtfied by soious 



mtALtJfOX • 


479 


proiltmticm and ttncaetaia. This period is called die ‘stage of secondary 
fewer’w 


The tesoperatum is high, 104 '’F. <« over, the pulse rapid, and breathing 
usually distrenedj in most cases there is sc»ne laryngitis and bronchitis. 
The padait becomes delirious, is unable to sleep, lies pluckii^ at the 
bedaothes, markedly prostrated and exhausted. 

In cases terminating favourably the temperature declines, and the tox- 
aemia grows less as the patient’s general condition improves, but he now 
enters a very trying and difficult period of convalescence, as when crusts 
form, and tne scabs gradually and slowly separate, this is accompanied 
by ctmsiderable irritation. Tim patient is faced with the knowledge that 
his dun will be pockmarked, and that it will be discoloured for many 
months. He requues constant encouragement to help him face the long 
isolation period which must pass before the last scab has sqiarated. 


VARIETIES OP SMALLPOX 

Modified smallpox occurs in those who are partly protected by vaccination, 
persons who have probably not been revaccinated. The symptoms in these 
cases are milder. 

Discrete smallpox describes the mildest form of unmodified smallpox 
when the lesions, or ‘pocks’, remain separate. 

Confluent smallpox describes the more severe forms where the rash is thick 
and the individual lesions coalesce. The accompanying symptoms aue 
severe. 

Malignant or kaemorrhagic smallpox is very severe and is characterized by 
bleeding under the skin and fixun the mucous membranes. The rash is 
haemorrhagic in character. 

Alastrm or variola minor is a form which becomes prevalent in countries 
where protective measures against smallpox are taken or where the 
majority of persons are immunized. Thu type may occur, in epidemics, 
but the symptoms are mild. 

Complications are numerous. Laryngitis, bronchitis and broncho-pneur- 
mania are comparatively common. Conjunctivitis occius in most serious 
cases, and really bad ones are complicate by iritis and corneal ulcer. Sepris 
results in oUiis media, adenitis, boils, carbuncles and abscesses. Bedsores are very 
common, especially if the parts of the skin on which the patient lies are 
covored by me rash. Hyperpyresda occurs during the stage of secondary fever 
Mbminsaia is present during the febrile stage and nepMtis and ureumia may 
occur. Abortion occun in pregnant womeiu 

Treatment. The description of the seriotu dc^ee of illness through 
whi^ the patient passes when the disease is at its height, followed by 
the per^ of depression when the scabs are separating, suggests the lines 
of nursing care which are necessary. The possibility of each complication 
mentioned riiould be borne in mind, and means taken to Keep the 
mouth, eyes, nose and ears as dean as pebble; while keeping the skin 
free exudate fimm the ruptured discharging pustules will go far to pre- 
vent the compUcatiom that might be due to sepsis. 

The paUfmt should be nursed in an airy, warm room; his diet should 
be nourii^i^ and fluids given fireely ; his urine should be tested for albumin 
daily uid his bowels kept in r^lar action. The apjffication of an icebag 



480 QAim OF INJ^CnOffS DI8EA8B8 

will help to relieve llie constant headache, and i^nghog i/dU tvslnce 
fever and also help to keq} the ddn dean. The application of antiseptic 
ibzoentadons to the discharging pusOUes asdst in clearing dsem; large 
pusoiles should be opened by incision with scissors, curved on the ilal^ 
followed by the implication of fomentations. Frequent spongii^ and hot 
bathing is of value in assisting the scabs to separate. 

VACCINIA 

Vaccinia or cowpox is the disease or condition which is transmitted to 
man when he is vaccinated, by inoculation with calf lymph, in order to 
protect him from aoaallpox. 

Healthy calves are inoculated on the skin of the abdomen; 96 hours 
later a crop of vesides appears, the exudate is collected and made into an 
emulsion with glycerine and put up in phials ready for use. 

The operation of vaccination is carried out imder strict aseptic 
technique. The skin of the area, arm or leg, is carefully deansed; but care 
must be taken that antiseptics are not used; it should be well washed, 
deansed with alcohol and washed again with sterile water, and then 
bed dry with a sterile towel. 

The physidan takes the capillary tube which contains the prepared 
calf lymph, breaks off each end and, by means of a small rubber blower, 
spreads the lymph on the prepared skin. He slightly scarifies the skin — 
through the lymph — but docs not draw blood. When dry the area is 
covert by dry sterile gauze. 

The course of vaccinia. An incubation period of three days elapses 
and then, if the vaednation ‘takes’, red papules appear; by the fifth day 
these change to vesides, and by the dghth day the contents become puru- 
lent. At this stage there is a definite area of induration around the crop <£ 
pustules; this lasts a few days and the pustules then begin to dry. The scab 
separates in less than three weeks, a pink scar remains, which gradually 
fades to white. The surface of a vaccination scar is stippled. 

Treatment. In the case of a vaccinated person it is all important to 
keep the area covered with sterile gauze, and to prevent the occurrence 
of any secondary infection. The vesides and pustules should be protected 
against the possibility of being knocked and ruptured, and the best result 
be obtained if they scab off, iminjured. If the whole arm is swollen 
during die stage of maturation it should be carried in a sling and hot 
fomentations may be necessary, and if a leg shows marked inflammation 
the patient should rest in bed for a few days. A saline aperient is given on 
the third day. 

Cotnplicalims are rare. The danger of secondary infection has already been 
mentioned. A mild d^ee ot adenitis may arise in the neighbouring lym- 
phatic glands. Eiysipelm may occur. 

Revaccinariom PifrRuryaairiadtton isusually performed at the age of from 
a to 6. months. Reoaccinatioa is recommended at the age of fixan 7 to 1 4 years; 
It is significant that in countries where revacemation it iptematicdly 
{nactfred nnallpox has been ontirdy stamped out. 



Chapter 31 

JPulmonaiy Tuberculosis (Sanatorium Nursing) 

JfftroducHm — PreeUspo^g factors — Sources of infection — Varieties — Changes in 
the tissues — Resistance toiifection — Preventive measures — Diafftostic proceebtres — 
Modes qf onset — Symptoms — Complications — Treatment and nursing— General 
treatmerU — Special nursing care— Treatment for relief of distressing symptoms — 
CoUcpse therapy — Moruddi drainage — Hints on hygieru to nurses 

{See also Thoracoplasty, p. 666 ) 


T uberculosis in so far as it is due to a micro-organism is an infectious 
disease. It is the commonest infectious disease in this country but 
differs from many of the others because the onset is insidious, often 
|>a8aes unnoticed and moreover the coiurse of the disease is long and cluonic 
m character. 

The incidence of tuberculosis rises and falls with the state of the health o 
the community and thk depends to a great extent on suitable food and 
good social conditions of living. A century ago tuberculosis had a high 
death rate. During the past 80 years the death rate has progressivdy 
fallen, from 1860-1900 ft fell by over 40 per cent. This improvement 
was due principally to amelioration of socM conditions, it began before 
the discovery of the tubercle bacillus by Koch in 1882 and before the 
establishment of Sanatorium treatment. 

There has been a progressive decline in the incidence of tuberculosis 
from i860 to the present day. Conditions of war usually results in some 
increase. During the present war there has been a slight rise in the 
number of deaths from pulmonary tuberculosis. This occurred in 1942, 
but since that day the incidence has declined again and with the present 
determination in the country to control tuberculosis it is hoped that it 
will be possible to eradicate this disease. 

Tuberculosis in the occupied countries and amongst prisoners of 
war where in both cases food has been in short supply and the 
conditions of living have been poor have resulted in an increase in this 
dkease. 

Early Recogrdtbm, At the present time the tuberculosis service is 
developing in some parts of the country and the facilities required for early 
recognition of the disease,. i.e. X-ray examination of chest, labcnratory 
examination of sputum and Mantoux’s test are available. Physicians and 
nurses sire being specially trained to deal with early cases, to teach the 
importance of prc^hyias^ in the home and workshop, to encourage the 
regular exnmmation of eertain groups, to educate the public to elinunate 
their present fears of the terms ‘tuborculosis’, ‘coiuumptive’, ‘sana- 
torium’ suvl such^^^ terms and to understand the importance of the 
early recognitiona of symptoms and early treatment or the disease in 
order *bat the source m infection bring found it may be removed and 
that disease in the ini^vidual m^ be arrested. When doctors, nurses, 

48* 



483 PULMONARY TX 7 BSRCULOBI 8 

patients and the puUic all work together thoi, and not till then, will 
tuberculosis be cffectiv^ controlled. 

PremOion. The tuberculosis service began by considoing treatment but 
in its development preventicm is now assuming its proper place. Preven- 
tion of disease should precede treatment; so it is with nursing, csuing 
fm: the patient, sick and in be4> is a great work, but pre^KUt^ diat 
illness is much more important, and helping a patient back ^ther to 
perfect health or to rehabilitation is secoi^ only to prevention. In 
tuborcuiosis it is important to teach the public what diis du^ue is aiul 
how it is transmitt^. 

Cause. Tuberculosis is due to a germ, the tubercle bacillus or mjnxh 
bacterism, vdiich because it is endued in a very resistant capsule is 
difficult to destroy. The covering membrane is weakened by ei^>osure 
to sunlight and heat, and then the germ is more eanly killed. 

The tubercle bacillus may settle in several parts of the body and 
cause changes there; for example it may settle in the lungs, bones, joints, 
lymphatic glands, abdtnnen, urinary tract, skin and meninges. There 
are two types of tubercle bacillus which chi^y affect man — the ‘huiiian’ 
which originates usually, in a lesion in the lung, and the *bovine* which 
is found in tuberculous cattle. Two other types are described \duch iidect 
birds and &h as the ‘avian’ and ‘cold-blooded’ types. 

Predisposing Factors. Hereditary. Tuberculosa is not hereditary in 
that, except very rarely indeed, babies are not bom with it, but babies 
who are bom into a family where there is a case are in contact with 
and subject probably to massive infection and they tend to develop 
pulmonary tuberculosis. The infection in these cases it usually a Mrvere 
one, and whore a primary infection of this type is contract^ during 
infancy it is generally fatal. A baby bom of a tuberculous mother win 
not, unless it should come into contact with some other source of in- 
fection, develop tuberculosis if it is removed fixun its mother and brought 
up away fiorn its dangerous environment. 

Race. Tuberculons is a disease of civilization. It has already been 
pointed out that where there is no tuberculosis there is no immunity. 
For example those idio lived in country districts are found to be Mantoux- 
negative which shows that they have never been infected and have 
not therdbre devdoped any immunity. Whereas 60 per cent, of town 
dwellers are Mantoux-positive demonstrating that they have been in- 
fected and have theretore developed some immunity. Immunity thus 
devdoped is a safeguard. The Insh, Weldi and Scottish Highlanders 
living in country districts are particularly vulnerable to tu&rculosis 
and a number do contract the disease when they come into contact 
with h for the first time. 

Another po|Nilar dieory is diat certain types individuds hscve a 
gnater tendency to tubaculons than others. Those with a fine sldm 
milk and roses colouring, long eyelashes, long narrow chest and wingen 
scapulae are spolmn of as having a tubemhus dioAesis, But whh die ton* 
dei^ to develop an open air life and the increase hi outdow games 
the general health of the pc^mlation has unproved and this type of 
person is extremely rare. 

Age Ineidenee. When chiMim under devdop pulmonluy tU<beo< 
culons it is gamrally fetal iuid when tfeqtthed betweoa the of finoi 



tiTBimaiTiotn 483 

a io and young peo|rie tiTCtwoeii 

aam as yeaiv ibnii ’die ma^cnity age ^up In which tuberctdodi 
Poults and in ^eie die ^^iseate aaiumes a cWi^ course. It is essential 
that the disease shocdd he fect^nized early, when, in the majority ctf 
instances, it can be arrested. If neglected the disease will progress and 
enter the advanced stage ^en there will be little hope of return to 
anytMi^ approachi^ a normal life. It diouJd be remembered that the 
firtt ‘su^n of life' is taken at the age of 15 to qo. Ibe individual b^ns 
then either to earn his living or to take seriously some aspect of work 
or study. He is cdT an age in which he is still developing and u thraefere 
very vulneraMe to tuberculosis and it is essential that his resistance 
dionld be midntained by good feod and healthy living. He should make 
semifole use of his Imure time for rest and recreation, diould spend some 
of his time in open air occupations and obtain sufikient deep under 
healthy conditions. Any persons in this age group such as nurses should 
be given all the help mey need to enable them to maintain resistance 
to infection and all the protection which is available for the prevention 
of infection if aikl when they may be iMrought into contact with tuber- 
cttiods (see also page 496). 

Sources and modes of Infection* The human tubercle bacillus 
is the most dangerous organism. Pulmonary tuberculosis is caused almost 
entirely by this type; the bovine type being mainly the cause of infection 
of the ab^mem ixtnes, joints and glands. 

Tlie principal sources of infection by the human bacillus are droplet 
infection from those suffering from pulmonary tuberculosis and the 
inhaling of ir^eckd dust and Sried sputum carried on particles in the air. 

The tubercle bacillus taken in as food is usually the ‘bovine’ type which 
is swallowed principally in milk and also in eating butter, cheese and 
the meat of infected animals. The ‘human’ tubercle bacillus, however, 
may, and not infi^uently does, gain access to any type of food and it 
is therefore most important to have control exercised over those who 
handle food in the home, restaurant, and provision store, particularly 
with regard to milk. Organisnis may enter thro^h the mucous mem- 
branes and through the abraded skin by uu^ulation, smd probably most 
cases of dun tub^ulosis are contracted in this way. 

Uobtg tubarele bacilli are to be found wherever people group together 
as in places of entertainment, public conveyances, restaurants and air 
raid shelters, l^ighty per cent, of the adults in towns are infected. 'The 
mjyority are unaware of it; either there arc, or were, no symptoms, or 
the disturbance is, or wa^ so slight that no notice was taken of it. The 
initial dc>s^ of IniTection passes unnoticed therefofe because the power 
of resisted ^ the mbtddual is sufficient to overcome the strength, or 
virulence, oTthe mvadlng and so the disease does not devdop. 

Butina l^cases, a veryjfewinde^, resistance is low, the micro-organisms 
increase mffitiply and pulmozuiry tuberculosis is establish^. 

Vtttietle#* Pulmonary tuberculosis may be an aaOt condition with 
a n^id onset which is a type most ofren met with and tetidk to run a short 
course in children^ or it may be subatuU as are the majmity of cases. 
The laihmr foim k betwe«ti the a^ df 18 to 30 

and in tim Case particali^ idien die disease is diagnosed ea^ 

this feNrm of be aitestedr Ml&ny an acute 



484 PULMONARY TUBEROULOSIt 

form when areas of disease arise in a number of organs, including the 
lunc^, at the same time. These minute areas or tubercles resemble millet 
seeds. In the majority of instances miliary tuberculosis runs a rapid 
course, ending fatally, though chronic casra do arise and the disease in 
these can be arrested. 

Changes in the Tissues. When tubercle bacilli invade the t^ues 
certain characteristic changes occur which lead to the formation of a 
primary lesion or tubercle. 

A tubercle begins by the presence in the tissues of a little colony of 
tubercle bacilli. These become surrounded by sonxe giant cells formed 
from mononuclear ceEs and layers of epitheloid cells enclosed by a zone 
of lymphocytes. In this way the tubercle bacilli are imprisoned and, 
according to the changes wMch take place in and around the tubercle 
so formed, the disease progresses, remains quiescent or heals. Tubercles 
are visible to the naked eye and vary in size from a pin’s point to a 
pin’s head. 

A number of terms have been used in describing the type of tuber- 
culosis from which a patient is suffering. Laennec’s original classification 
is as follows: 

Consolidation. Inflanunatory changes occur and the lung becomes airless 
and solid. 

Softening or caseation. As the result of changes which are the beginning 
of ulceration, the centre of the mass or tubercle softens. The contents are 
at first of the consistence of a cheesy mass, later liquefaction occurs. 

Cavity formation. Ulceration progresses until sufficient tissue has been 
destroyed to result in the formation of a cavity. This becomes filled with 
infective material. When the cavity remains closed the patient is des- 
cribed as having a ‘closed tuberculosis’, but when the cavity involves a 
bronchial tube die secretion gets into the tube and is coughed up as 
sputum. This state of affairs is described as an ‘open tuberculosis’. 

Sputum from a cavity is expelled by the lashing movements of the cilia 
which line the tube carrying the secretion onwards and upwards towards 
the larynx; by the constant movement of the bronchial tubes which 
helps to keep the secretion moving, and by coughing which by the ex- 
pulsive expiration involved forces air out of the tubes and carries with it 
any secretion or other foreign body contained in the bronchial tubes. 

Fibrosis. This occurs when the tissues are resisting the invading or- 
ganisms. After an initial inflammatory reaction cells multiply round the 
infected area and a barrier of fibrous tissue is formed. So long as this is 
complete the disease does not spread. This fibrous tissue contracts and 
forms scars and cicatrices which are intended by nature to close or shut 
off the cavity but do not always produce that effect. Sometimes these 
fibrous bands act as adhesions which may fasten the lung to the chest wall 
and so prevent movement, or they may exert a pull in Afferent directions 
and prevent the closure of a cavity which might otherwise heal. In this 
way the period of incapacity of the patient may be prolonged until these 
adhesions are dealt with surgically. 

Calcification. Sometimes lime salts become deposited in a tubercle 
which hardens and becon^ separated from the lung tissue. It^may 
remain in the limg or it may be coughed up as a ‘lung stone’. ^ 
These various stages representing the changes taking place in the 



PULMONARY TUBERCULOSIS 485 

lung after invasioa by tubercle bacillus may all be present in the 
same patient. For example tiiere may be areas of caseation, cavities and 
fibrosis in the same lung. 

Resistance to Infection. Two factors arc principally concerned in 
all infections (a) the virulence of the invading organisms and (b) the 
resistance of the individual. Both these factors are concerned in tuber- 
culosis and in particular the resistance of the individual plays a very 
important part. 

The viruletice of an organism depends on the conditions under which it 
has lived or existed. The tubercle bacillus, for example, will have a low 
virulence if the conditions imder which it has lived are unfavourable, 
but if favourable, such as those existing in an advanced progressive case 
of pulmonary tuberculosis, then the organisms will be very virulent 
and likely to cause active disease if inhaled in any numbers, particularly 
when the individual infected by these organisms is tired, run down and 
overworked or anxious. 

Factors which lower resistance include exposure to infection, particularly 
firequent exposure such as occurs when living with a tuberciilom member 
of me family, working in a confined space with a tuberculous colleague. 
When a teacher has tuberculosis infection is rapidly spread to the children. 
Nurses need all the precautions that can be taken by them and on their 
behalf when nursing cases of pulmonary tuberculosis in order to avoid 
infection, particularly when nursing patients with advanced disease who 
arc too ill to take ordinary precautions against spreading the disease by 
means of droplet infection and by sputum. 

Malnutrition. There is no better example of the ravages which malnu- 
trition can make and the increased incidence of, and mortality in, pul- 
monary tuberculosis than that occurring in the enemy occupied coun- 
tries at the present time. War brings a world shortage of food. During 
the last war it was observed that deaths fi'om tuberculosis increased in 
the neutral as well as in the belligerent countries. 

Overcrowding means that people are congregated together so that in- 
fection is more easily conveyed. 

Foot housing. This means ^at there is probably overcrowding and a 
low standard of hygiene and sanitation. There is ziko insufficient income 
to ensure enough mod. 

Low Standard of living. Poverty may exist in good as well as in poor 
houses. It means that there is insufficient food and added to this there is 
anxiety as to how the next supplies will be obtained. 

Dirt and neglect usually go together. They may be the result of bad 
housing, overcrowding and a low standard of living, or they may be the 
result of apathy, produced by the depressing conditions under which 
the poor live, which should never be ^owed. Apathy and indifference 
may be due to ill health and/or mental deterioration, and this may result 
in seriotis neglect of health. 

Certain Occupations are accepted as a specific hazard such as those in 
which silica is inhaled. Silica dust injiues the lungs and so predisposes a 
subject to tuberculosis. 

Lmg hours and Fatigue. Long hours, particularly when the span of day 
is loi^, are fatiguing and lower the resistance. A day spread over beyond 
la hours, to 13 or 14 hours for ommple, is not compensated by off duty 



486 ptn^MoMAitv TUBSitctJLoats 

time no matter how libeial this may he. Inegular hours of work and 
irregular meals also lower the resistance to inmcdon. 

Mental Factors, such as worry and anxiety, tend to lessen the ability to 
eat and sleep, and these also play their part in lowering the resistance 
to infection. 

Pregneauy. A pregnant woman; is usually very fit and well, it is in the 
early weeks and months following parturition that pulmonary tuber- 
culosis does, in some cases, appear and therefore everything that could 
be done both during pregnancy and after the birth of the child to prevent 
this lowering of the redstance of the mother should be carried out. 

Slimming. Happily slimming is not in &8hion at present. Girls are more 
sensible, the majority look best in uniform if they are well covered; 
most women are busily engaged in war work and are thinking less of 
themselves and their fads. Nevertheless there is many a girl suffering firom 
tuberculosis because she thought more of her ‘line’ than of her he^th. 

Diabetes. There is an increased incidence of pulmonary tuberculosis in 
diabetics probably because this is a disease which affects nutrition and 
also because a majority of young persons who get diabetes do so between 
the ages of 15 and 20, which is the age when the body is most vulnerable 
to attack by the tub^cle bacillus. 

Preventive measures. If spread of infection could be prevented 
and the resistance of the individual adequately maintained then tuber- 
culosis would be controlled. Enough has been said (above) about the 
factors which lower the resistance of the body to indicate how it may 
best be maintained. 

Immunity. As already mentioned (p. 482^ 80 per cent, of adults in 
towns have been infected with tuberculosis, though not clinically in- 
fected. Soon after Koch discovered the tubercle bacillus in 1891, he 
discovered also the important fact that a primary infection rendered the 
subject sensitive to the tubercle bacillus. This discovery was called Koch’s 
phenomenon, it demonstrated that the subject previously infected 
became sensitive. To this phenomenon the term all^gy is now applied, 
and the test most commonly employed to determine its presence is the 
Mantoux test. 

Tuberculin Tests and Mantoux' s Test. For this purpose a preparation of 
tuberculin which is made of dead tubercle bacilli m ^ycerin, known as 
old tuberculin (O.T.), is used. Tuberculin is standarchzed by its action 
on guinea pigs which are sensitized by previous infection with tubercle 
bacilli. The dilutions in sterile saline generally used for Mantoux’s test are: 

1 — 10,000 (0.01 mg. tuberculin in o.i. c.c.) 

I — 1,000 (0.1 „ „ „ O.I.C.C.) 

I — 100 (i.o „ „ „ O.I. c.c.) 

The test is made by intradermal injection of the most dilute preparatkm 

into the skin of the forearm. If no reaction follows, the next dilution is 
employed. A positive reaction is demonstrated by a swollen indurated 
area which appears after 2, 3 or 4 days, persists for 48 hours and then 
fades rapidly. Healthy inftmts and persons who have lived protected lives 
in the country and at the sea give no reaction. They arc Mhmtoux-nega- 
tivc whidi shows that they have not yet received their primary mfbctmn 
and it would be unwise to eiqxise di^ individuals to cosAact with cases 
of tuberculosis until they have, in the normal way, by muting with the 



PtrLMOKARY TUBERGULOStS 487 

comminity-in a populated area, recdved their first dose of infection and 
developed some degree of immunity. They would then show a positive 
reaction and becoxne Mantoux-positive. 

Patch Test. For this test a preparation of dried tuberculin is taken and 
a piece of filtering paper is saturated with it. These pieces of paper are 
each one square centimetre in area. They arc fixed on to a piece of 
adhesive tape in the following arrangement: Human Control Bovine. 
One square carries human tuberculin, one bovine and a central square is a 
control saturated with glycerine broth. 

When using the test, in the case of children the patch is applied over the 
stemiun ; in infants over the upper spine and in adults over the inner aspect 
of the forearm. The skin is cleansed with acetone. Antiseptics should not 
be used. The strip is left in contact for 48 hours. It is then removed. The 
result is read 48 hours later. A positive reaction is indicated by an infiltrated 
reddened area, the control patch remaining pale. In a negative reaction all 
the areas are pale. 

The patch test is considered as reliable for infants and children as the 
Mantoux test is in adults. 

Other tests such as those of Calmette, Moro and Von Pirquet are not 
employed at the present time. 

Immumzation. It is not possible at present to produce either a known 
degree or a protective degree- of immunity to tuberculosis such as can 
for example be procured in smallpox, diphtheria, scarlet fever and typhoid 
fever. £x{>eriments have been made both by using virulent tubercle 
bacilli and killed bacilli. Tuberculin is a preparation of killed bacilli 
which is used for the tests mentioned above. Tuberculin given as a 
series of injections has also been tried in the treatment of tuberculosis 
but the results of this method of treatment have been difficult to assess. 

Prophylactic Treatment (Bacille Galmettc-Guerin B.C.G.) is a means 
which was first developed by two physicians in Paris of giving attenuated 
bovine tubercle bacilli to new-born infants. The organisms are rendered 
avirulent by 280 passages over a number of years on potato-glycerin. 
Unfortunately, owing to an accident at Lisbeck, when the vaccine used 
was contaminated by virulent tubercle bacilli, a number of infants died 
of tuberculosis. B.G.C. vaccine has been tried in Norway and Canada, 
its possible value is being discussed in this country, but up to the present 
time medical opinion is divided as to whether it is siafe to use it in man. 
Pasteurization of Milk is essential to eliminate the bovine bacillus. 
Voluntary segregation of patients in a sanatorium for treatment until a 
tuberculosis lesion has closed, and the danger of spread of infection to the 
community is minimized, should be taught and encouraged. 

Widespread propaganda in which nurses can play a great part is essential, 
and the public must learn: 

(1) that tuberculosis is an infectious disease and the ways in which 
it may be spread. 

(2) that it is not a disgrace to have, or have had tuberculosis, and 
that there is no stigma attached to having been treated in a sanatorium. 

(S) that tuberculosis, though one of die greatest social evils of our 
day, is preventaWe and t^en in die early stages is curable, and that 
everyone should be famili ar with the means of detecting this disease 
at its very beginning. 



488 PULMONARY TUBERCULOSIS 

Diagnostic procedtuTOs. The histmy of the diagnoi^ of tuberculo^ 
is of interest. Hiysical examination of the chest by auscultation was recom* 
mended by Laennec who invented the stethoscope. A physician named 
Williams paid great importance to the excursions of the diaphragm and 
found that these were diminished on the diseased side in pulmonary 
tuberculosis. Physical examination includes percussion, auscultation, palpa- 
tion and observation. The two last are applied particularly to noting the 
movements of the chest wail and the excursions of the diaphragm. 

The lesions found in the post-mortem examination of patients who died 
of tuberculosis were shown to contain small nodules which were called 
tubercles. These lesions were thought by mimy physicians to contain living 
germs even before Koch made his discovery of the tubercle bacillus in idgi. 
ITie discovery by Rontgen of X rays in 1895 which were employed com- 
paratively soon in the diagnosis of pulmonary tuberculosis was the next 
step in diagnostic procedure and test. The tuberculin test, also elaborated 
by Koch and at present employed by means of Mantoux’s test, followed. 

At the present time the means available for the early diagnosis of 
pulmonary tuberculosis include: 

X-ray examination of the chest is now developed to so fine a means of 
scientific investigation that the earliest signs of disease can be detected. 
Mass miniature radiography hats recendy been employed for the examination 
of groups of persons who, by reason of the nature of their work, the stress 
and strain with its resulting fatigue to which they may be exposed, or 
who by virtue of their particular age-group might be suspected of a 
tendency or liability, under certain given circumstances, to contract the 
disease. 

Bronchoscopy is employed under special circumstances as an aid in 
diagnosis. 

Examination of sputum. Facilities for laboratory examination of sputum 
are now available to all physicians who care to make use of it. 

Blood examination. The sedimentation rate of red blood cells is estimated 
because in acute tuberculous infections there is a considerable increase 
in sedimentation rate. Special serological tests are also employed. 

Modes of Onset. It is very important to be familiar with the modes 
of onset in tuberculosis. Many of these symptoms will be conunon to a 
number of other conditions but their cause should be investigated. The 
symptoms of onset will occur in one of two different forms. Either general 
syniptoms will be set up, due to the toxins circulating in the blood stream. 
These include malaise, a tendency to be easily fatigued, anaemia and 
breathlessness, amenorrhoea, loss of appetite, indigestion, nausea, palpi- 
tation, repeated colds in the head, sweating, particulariy at nig^t, 
increa^ pulse rate, rise of temperature in &e evening and gradual 
progressive loss of weight. 

LmoI symptoms associated with the respiratory tract may arise. There 
may be cough, a little irritating cough which does not improve, or an 
attack of coughing may occur on waking each morning, ^mtum may or 
may not be present. Haemoptysis. This may be a little staining of sputum, 
occasional slight spitting of blood or a severe attack may occur. Pleurisy 
is a iairly common mode of onset. The subject may have had an attack 
of pleurisy some years previously or the 6 nt attadc may be the onset 
of tuberculosis. ^ attack of pleurisy should never be ignored. 



PULMONARY TUBERCULOSIS 489 

Symptoms. A very great variety of symptonu may occiur in most 
cases of pulmonary tul^rculosis, the foUovraig group may be considered 
fairly characteristic: 

Cotigh, which is and hacking at first, later loose and, in severe 
cases, paroxysmal in character. 

Sputum, at first scanty and mucoid, then copious and muco-p\iru- 
lent; in all cases it may be blood-stained and, in cases with cavity 
formation, it is nummular in character (see p. 65). 

Dyspnoea is present in all acute cases, and in chronic cases which 
arc not responding to treatment. 

Pain may be present either as the result of pleurisy or of pleural 
adhesions. 

Temperature. All cases with toxaemia show a rise in temperature, and 
acute cases run a high temperature which may be either constant, 
intermittent or remittent. In some cases the fever is inverse in type 
(see p. 3a); this is considered to be a serious sign. 

WasHng is marked when the disease is progressive. 

Sweating is very troublesome, and so-called night sweats are disturb- 
ing to the patient’s rest as his clothing becomes soaked with sweat 
and has to be changed frequently. 

Clubbing of the fingers occurs in most cases of advanced pulmonaiy 
tuberculosis. 

Complications. Many of the distressing symptoms met with in 
pulmonary tuberculosis may be regarded as complications; laryngitis 
may be catarrhal or tul>erculous, pleuri^ may be dry or with effusjon, 
haemoptysis may be slight or severe. I>ess common complications include 
spontaneous pneumothorax, bronchitis, asthma, bronchiectasis and empyema. 

Spread of infection to other parts of the body may give rise to intestinal 
tuberculosis, fistula-in-ano, meningitis, tuberculous infection of the 
lymphatic glands, bones, joints and urinary tract. 

Treatment and nursing. Rest is of importance, and febrile cases will 
be ordered absolute rest, until the temperature has been down for several 
weeks, then graduated movements will be permitted. 

The aim of the treatment is to relieve toxaemia, and therefore rest is 
maintained until signs of toxaemia have abated. Another important point 
in treatment is to help the patient to build up a resistance to the disease, 
and this is carefully carried out by giving him short periods of graduated 
exercise. Each time this exertion acts as a slight stimulus to the patient’s 
body and a certain small amount of toxin is poured into the circulation, 
and by this means he is actually being given a dose of his own toxin 
in much the same way that vaccine treatment would act. This form of 
treatment is described as graduated exercise and work, and it is important 
for the nurse to realize that the success of the treatment throughout 
depends on a progressive increase, provided that the temperature remains 
normal and the weight stationary, and that untoward symptoms can be 
avoided, such as increased cough and sputum. Shoifid either of these 
conditions arise, a return to a quieter life and in some cases to a further 
period of rest would have to be considered. 

In the care of a padent with pulmonary tuberculosis, food, fiesh air, 
observation of weight and observation of sputum are very important. 



490 PULMONAltY TtnSRCtTLOSa 

Tlw dut will be of high calorie value, ^ described on p. 288, but in many 
cases the nurse will find her resources taxed to the utmost to persuade 
the patient to take the amount of food he reaUy requires. As far as pos- 
sible the patient should sleep in the open air day and night; if he is 
indoors the windows should always be open and his bed should face an 
open window. When patients arc nursed indoors there should be 12 feet 
of wall space between the beds in the ward if possible. 

The weight should be carefully charted and me patient weighed every 
week, at Ae same time of day, and wearing exactly the same clothing 
each time. 

With regard to the sputum, the quantity and character should be care- 
fully noted. It is definitely infectious in cases of open tuberculosis and 
it is best to consider it so in all cases. It may be received in sputum cups 
or flasks, which should be sterilized every day. The patient should use 
only paper handkerchief which must be burned after use, and he should 
be provided with a calico pocket in which to keep this handkerchief to 
avoid soiling either his personal clothing or the bedclothing. This calico 
pocket shoidd be boiled or steam disinfected before it is washed. 

Special nursing care. A patient with pulmonary tuberculosis may 
be only slighdy ill or he may be confined to bed suffering firom many 
distressing symptoms and marked weakness and prostration. The nurse 
who undertakes sanatorium work should be able to adapt herself readily 
to the physical state and temperament of her patients. 

A patient on absolute rest has to be helped to be helpless. It will help 
him to rest if he is treated skilfully, if his bed is carefully and well made 
and he is cleverly handled when being washed, so that he feels he is being 
attended to by one who cares for the work she is doing and who, whilst 
being businesslike about it, can at the same time spare a moment to 
sp>eak and smile and keep him interested so that the treatment, which 
might otherwise be dreaded, becomes a pleasure to be anticipated. 

When absolute rest is ordered, a patient requires to be fed becaxise he 
must be spared all exertion. To many, it is very irksome to have another 
person put food into one’s mouth, and to avoid irritation this must be 
done with care and tact. 

Patients who arc very ill, and running a temperature, may not be able 
to take solid food and may be fed on fluids and semi-solids and jellies. 
Care should be taken to see that the patient takes the amount of food in 
calories that is ordered. In all cases it is possible to dii^ise cream in 
soups and sweets, and cases have been known where patients who had 
been fat-shy all their lives have taken their allotted portion disguised in 
this way. 

Most cases of pulmonary tuberculosis even when allowed up will be on dejmiU 
periods of rest; these arc usually planned to be taken before and after meals. 
The importance of rest before the two main meals, dinner and supper, 
should be impressed on the patient and he should have a good rest mter 
the midday meal also. Patients must be taught that these rest periods mui^ 
be real rest and no work or recreation whkdi can be performed when lying 
down should be permitted. They ought not to read but relax, and as 
the art of relaxation can be taught, the nurse in a sanatorium who makes, 
one, or even two rounds amongst her patients durii^ the rest hour, 
showing her interest in each, and encouraging by a dieeriul word that 



PVLUQNAIIY TUBBROULOSlt 491 

will ifthibit Rny restlosness ahe may notice, will do much to help her 
patients to bear what might be irksome, until as habit forms they may 
perham come even to enjoy their rest. 

Motet nuff be given ahout personal clothing. Many patients wrap up too 
much; in a numb«' of instances cases of pulmonary tub^culosis tend to 
perspire a good deal and excess of clothing increases this. If a patient 
can be brought to see that he is in inore danger of Iwing chilled by this 
than by the movement of air he notices when sleeping out of doors, in 
a shelter, or in a room with all the windows open, this would be an 
advantage. The nurse might point out how few persons living habitually 
in the open air get colds. But this must not be done at the expense of 
comfort and all cases of pulmonary tuberculosis should always be warm 
enough. When in bed in the open air in winter they should wear clothing, 
which comes well up round the ne<^, the hands should be protected 
from chapping, and the feet kept warm by properly protected hot water 
bottles. 

Painful and distressing symptoms may depress and weary a 
patient. Haemoptysis is a dreaded complication, many patients being 
frightened by tiny streaks of blood in the sputum, and even the slightest 
sign of haemoptysis should always be reported to the doctor, who will 
decide whether what is seen suggests a tl^atened attack of haemoptysis 
or is comparatively unimportant, and the nurse must try and help the 
patient to have alwolutc confidence in his decision and should take all 
steps to sec that the patient docs not wony, and if the doctor has decided 
the occasion is of no importance the patient must not be permitted to act 
as an invalid by staying in bed and refusing food. 

When a patient has a severe attack of haemoptysis the nurse must remain by 
his side, send for the doctor — an emergency tray is usually ready in a 
sanatorium, contauning the remedies the physician is in the habit of 
ordering. Keeping the patient still the nurse should reassure him, clear 
his mouth of blooddot. Keep the blood he has brought up out of his sight 
and remove all traces of bk>od from his mouth and clothing. She must 
be encouraging, as the patient will be fnghtened; feeling his pi^e, she 
should nod her heswi or make some other movement indicating her 
satisfaction with her findings; then, wiping the sweat from his brow and 
putting his head on the pillow he may relax and rest, re^ured. 

After an attack of haemoptysis the patient will be kept in bed, his diet 
will be light and absolute rest may be ordered. He should be watched 
for any rccxirrcnce of the symptom. 

Breathlessness is apt to be distressing, and the patient may have to be 
propped up in bed. The doctor will order any drugs necessary. The nurse 
shouui sec if support of the chest gives relief, and she might support the 
patient’s head during an attack of dyspnoea; even if it docs not relieve 
the condition, which is unlikely, at least it lets the distressed patient 
realize that she is willing and anxious to help him and the proximity of a 
sympathetic nurse gives mental relief. 

Pem in the chest may be due to pleurisy or it may be muscular in origin. 
The doctor should be informed of the onset of pain and in the meantime 
the nurse might rub some liniment gendy in ai^ cover the painful part 
widt a pad of warm cotton wool or hold a lightly filled warm water 
bottle to the painliil area. Strapping the chest will usually give relicfj 



492 PULMONARY TURSIICULOSIS 

but this is better left until the doctor has been, as he will want to examine 
the chest first. 

J^ausea, indigesHm, vomit^ and diarrhoea are symptoms which so very 
commonly accompany pulmonary tuberculosis and increase the difficulty 
of feeding a patient. These symptoms necessitate altering the diet and 
making experiments to try and discover when the patient can eat and, 
if he is vomiting, what he can retain. In cases where vomiting is marked, 
only small quandties of beef extracts, champagne and glucose may be 
tolerated during an attack. 

Diarrhoea often indicates infection of the small intcstine^tuberculous 
enteritis. The doctor will order medicines and perhaps suggest trying 
peptonized foods, arrowroot and Benger’s food until the attack may abate. 
As in serioiis attacks of vomiting, very little of anything can be taken 
during a bad attack, and the provision of foods and fluid acceptable to a 
patient in these distressing circumstances taxes the resources of a nurse 
to the utmost. 

Pharyngitis^ laryngitis and loss of voice. An alkaline mouth-wash is an 
excellent remedy for the slight mucoid secretion many patients with pul- 
monary tubcrciilosis complain of first thing in the morning. When the 
larynx is affected the voice is usually affected also, and the only way to 
rest this organ is to rest the voice. 

To be forbidden to speak is very trying, and keeping silence often 
makes a patient depress^; the nurse must adapt herself to the new con- 
ditions and chatter pleasantly and agreeably, never expecting to be 
answered or using conversation which might provoke, or tend to provoke, 
an answer from a patient bidden to be silent. She may tell cheerful 
stories of what is happening amongst the others; recount items of interest 
she has read, describe the last picture she saw, if this is a suitable subject, 
and so on. The patient may be irritated at not being able to tell her of 
his interests, but if she has only one or two patients she might try to read 
the same newspaper and say did you see this — she could be answered by 
a nod or shake of the head — and then go on to say what in it has interested 
her. The patient will read and think, and perhaps write a note for the 
nurse to consider, and talk about on her next visit. 

When there is pain and difficulty in swallowing, the diet may have 
to be modified, and irritating or hard foods omitted. Local treatment 
or inhalations may be ordered, the nurse may have to encourage a patient 
to persevere with an inhalation, or in the use of an inhaler he dislikes. 

Sleeplessness and night sweats. Sleeplessness and its treatment have been 
described on p. 338. Night sweats may be the discomfort keeping a 
patient awake. In a mild form night sweats may be induced by excessive 
bedclothing; sweating may occur in a patient with even a slight rise of 
temperature as the temperature declines during the early morning hours 
and the skin acts profusely. In the majority of instances night sweats 
occur most frequently in acute cases and in others towards the last stages 
of illness. 

The sweating is usually severe enough to cause the dothing, bed- 
clothing and mattress to be thoroughly wet. In some sanatoria the 
patients sleep on rush matting, the sweat being absorbed by the matting, 
which dries quickly. The patient should be rubbed down, Or sponged if 
necessary, if he would like to be sponged, and it will not waken hun so 
thorougMy ^t he may not sleep again. He should have dry cl^n 



PULMONARY TUBRR0UL0S18 . 493 

dodiing Rjid be given a drinks and if his feet are not wann he should 
have a hot water bottle. 

Some physicians ordor a patient small doses of belladonna fisr the 
relief of night sweats. 

Fern. A rise of temperature usually occurs in most cases of pulmonary 
tuberculosis. In some the type of fever is inverse, in others the patients 
have a high temperature at six o’clock in the evening but intermissions 
occur in the early morning. 

When the temperature is very high, tepid sponging may be ordered. 
When in charge of a patient who is having a rise of temperature each 
evening the nurse will find he complains of headache, malaise and feels 
hot and uncomfortable, and she can help to relieve these distressing 
symptoms by performing his evening bath and toilet with care, aiming 
at reducing the heat of the body, and increasing his comfort so that he 
may obtain rest and perhaps go to sleep. 

In a patient with pulmonary tuberculosb even a slight rise of tem- 
perature, loo-ioi® F., is usu^y due to an increase of toxaemia and 
indicates the need for rest. 

A patient who is having a marked rise of temperature each evening 
may be unable to take his usual amount of food for supper, and this will 
necessitate a rearrangement of the diet so that more food is taken at 
the other two meals during the day. 

Getting up. When patients with pulmonary tuberculosis are getting up 
out of bed, great care must be taken to sec that they do not exert them- 
selves excessively, and that they imderstand thoroughly the necessity for 
leading a comparatively quiet life; they should rest conscientiously for 
half an hour on their b^ before each of the two main meals of the day, 
and after the midday meal they should rest, and if possible sleep for an 
hour to an hour and a half. 

On discharge from hospital it is important that patients should be able 
to continue the mode of life which they have learnt to use during their 
hospital treatment, particularly with regard to the prevention of infection 
to others, and this should be their guide on returning home. The nurse 
should take the opportvmity of impressing on the patient the need for 
having a comparatively early bedtime, and a fixed time of rising; the 
necessity of having good regular meals; and that, with regard to recrea- 
tions, excessive exertion and excitement should be avoided, as well as 
anything which might lead to the infection of other people, such as 
dancing, the use of playing cards and so on. The occupation a patient 
chooses on leaving hospital should, as far as possible, enable him to live 
the type of life that he has ^own used to. 

A number of supplementary treatments are employed during the 
treatment of cases of pulmonary tuberculosis in hospital and sanatorium 
including various forms of collapse therapy, monmdi drainage of lung 
cavities, sanocrysin and vaccine therapy. 

Collapse Therapy. The operations which are undertaken in the 
treatment of pulmonary tuberculosis, are based on the principle of 
collapsii^ ^e lung in order to bring the walls of cavities into such 
approidmation that healing may take place. This treatment results in 



494 rvtuoamY ruBBRotnudns 

expdling, in open caMS, the secretion contained itt du; cavities, so that 
it is coughed up. In this way improvement is brought about in the 
general ctmdition of the patient because the pus and secretion which 
is causing toxaemia is first diminbhed and finally removed. The healing 
of the cavity allows the wound in the lung to dose and therefore the 
source of infection to odiers, i.e., an open tuberculosis, is removed (see 
below). At the same time die lung is rested because it is put out of 
action. 

Artificial pneumothorax is employed when thin-walled cavities are present 
and when the disease is mainly affecting one lung, although bilateral 
pneumothorax is also employed in selected cases. In early cases this 
may be employed at the banning of treatment. In other cases it is used 
when a period of rat in bed doa not rault in a fall of temperature to 
iK>rmal. When an artificial pneumothorax can be adequately established 
it is maintained for an indefinite period. Failure to atablish an artificial 
pneumothorax may be due to adhaions which prevent the lung from 
collapsing; failure to maintain it may be due to complications, the 
commonat being pleural effusion. 

Pneumoperitoneum. Passing air in to the peritoneum is employed in 
casa which may not rapond to pneumothorax probably because the 
cavity in the lung lia deep. A phrenic crush usutdly preceda pneumo- 
peritoneum in order to ensure that the diaphragm is as high as possible. 

Before operation the patient’s bladder must be emptied as otherwise 
it may be perforated. A needle is passed into the upper part of the 
peritoneal cavity, above the .level of the umbilicus, either in the middle 
line or a little to the right. Air is then introduced by means of the Lilling- 
ston-Pearson apparatus. The amount introduced varies, and is determined 
by the pressure shown on the manometer and subsequent X-ray examina- 
tion. Refills are required more firequently than in the case of pneumo- 
thorax. 

Oleothorax is the injection of oil into the pleural cavity. This measme 
is not ofren used as the oil is not absorbed and sepsis may result. 

Apicolysis is the injection of paraffin wax between the chat wall and 
the parietal pleura. This measure aims at collapse of the apex of the 
lung. As it may be attended by complications it is not often used. 

Pkretttcotomy. The nerve which supplia the diaphragm may be crushed 
(phrenic crush), or it may be divided (phrenic avulsion). A phrenic crush 
paralysa the ^aphragm for about six months and the diaphragm risa 
about two incha. 

A small incudon is made at the side of the neck, the nerve is steadied 
by means of a hook and crushed between the blada of a pair of forceps. 
In avulsion the nerve is divided and drawn out firom its attachments in 
the thorax. 

Thoracoscopy. A small incision is made in the wall of the chat and an 
endoscope consisting of lamp and telescope is introduced into the i^ace 
provided by a pneumothorax. The presence of adhesions is invotigated. 
If adhaions are present an electro-cautery is passed in through a second 
cannula and the adhesions are divided. 

The small wound is closed by one stitch. A pad is sttapped over the 
opening and the patient is advbed to press on the pad when he wants 
to cou^, otherwise air, from the pneumothorax, may be forced out of 
the chat andj by entering the subcutaneous tissua tl^ air would cauie 



PI7LUOMAS.Y TUBBROULOSU 495 

a nuM iisrgicid anphysema. Subcutaneous emphysema is characterized 
by a crad^i^ sensation beneath the ddn around die wotmd. 

After the division of pleural adhesions the patient should be kept faiiiy 
quiet. There will generally be a rise in the temperature and an increase 
in the pulse rate if the opetadon was more than slight The reaction to 
be watched for and which may cause distress is pleural effusion. A 
collection of blood or pus severe enough to displace the trachea and heart 
would probably be accompanied by dyspnoea and a rising pulse rate. 

Extrapleural pneumothorax is performed by resecdon of a sh<nt length of 
the ba^ part (usually) of the fourth rib. The lung and the adherent 
parietal pleura are stripped ftxim the endothoracic fascia, air is then 
introduced under pressure to fill the space created and keep the lung 
from expanding. Coughing may be frequent both during and after the 
operation, and as this increases pressure in the space which has been 
formed, air may be forced out of the chest into the subcutaneous tissue 
causing surgical emphysema. Firm pressure of the hand over the wound 
whilst the patient is coughing will help to prevent emphysema spreading. 

In a few cases an emphysema may quickly spread up over the nedk 
and side of the face. This may seem alarming but it is not dangerous. 
Another complication is that serum, blood or pus may collect in the 
space created. If this happens the fluid must be removed by frequent 
aspiration. In some cases this complication, particularly where pus 
collects, will be accompanied by symptoms of fairly severe toxaemia. 

After this operation the patient needs the same care as after thoraco- 
plasty (see below) but the shock is less aeverc. 

Thoracoplasty is a major operation performed in pulmonary tubercu- 
losis. It consists in removing ribs so that the lung can fall inwards, thus 
providing permanent collapse. The operation is divided into stages 
so that the shock inflicted at any one stage is not more than the patient 
can bear. Blood grouping is carried out because the patient will probably 
require a blood transfusion. The type of patient selected for this operation 
usually has cavities in the upper part of the lui^ which have not res- 
pond^ to treatment by other formic of collapse therapy. The general 
condition of the patient must be as high as possible, but it must always 
be remembered that the patient upon whom this operation is to 
performed is already debilitated by his disease. For details of the operation 
and nursing care see p. 667. 

Monaldi Drainage of lung cavity. During the last two to three 
years a closed suction drainage (monaldi drainage) of cavities filled with 
secretion has been developed. It has proved useful in relieving toxaemia 
in cases which have not responded to artificial pneumothorax. It is also 
of value in reducing the size of cavities, thus modifying the extent of 
the operation should thoracoplasty afterwards need to be performed. 

A narrow tube is introduced into the cavity through a caimula. The 
free end of the narrow tube or catheter is attached to a suction pump 
which is kept working continuously and is coimected with a glass bottle 
into which the secretion from the cavity is drawn. If drainage can be 
established the cavity will be reduced in size. It may even disappear 
altogether. The secretion which would otherwise be coughed up is removed 
by suction. In some cases drainage is continued for many weeks, with 
progrestive improvement in the patient’s gmeral condition. As far as 



49^ PVLUONARY TUBBRCULOSIB 

nursing is conceamed, the chief point is to see that the oatheter is at^tched 
to the skin of the chest and cannot be pulled out of the cavity. The 
amount of secretion collected should be measured and charted The 
niirse should be £uniliar widi the apparatus and know how to adjust 
it in order to keep it working cffectivdy. If blood appears in the secretion 
it is usual to stop drainage for 2 to 3 days though the appearance of 
blood does not denote danger. The size of the cavity is watched by 
regular X-ray examination and Ihe gradual reduction in size is noted. 
When all the benefit that can be expected from the treatment has been 
obtained the tube is removed. As a general rule the tube track heals 
without difficulty though in a few cases tuberculous granulation tissue 
forms and^then healing takes longer. 


HINTS ON HYGIENE TO NURSES 

Tuberculosis is a preventable disease. Most hospitals and sanatoria have 
their own carefully-thought-out measures to prevent infection, which 
should be loyally observed. One of the functions of a sanatorium is to 
teach patients how to prevent spreading infection and how to live safely 
within certain limits. Instruction regarding the spread of infection and 
how this may be avoided is given to all grades of staff employed in a 
sanatorium. 

In pulmonary tuberculosis infection is conveyed by droplet infection, 
secretions from nose and mouth, handkerchiefs, sputum, and dust which 
contains bacilli from dried sputum and secretions. Patients should be 
taught to avoid spraying droplets from nose and mouth in speaking 
and laughing, to cover ffie nose sind mouth with a large handkerchirf 
when coughing and to use a sputum cup or flask for expectoration. 

When performing treatments at the bedside a nurse should see that 
the patient’s head is turned away from her, to one side; she should 
stand on the same side of the bed as the physician when he is examining 
a patient; avoid touching patient’s handkerchiefr or sputum cups except 
when wearing gloves, handle bedclOthing and patient’s personal clothing 
carefully so that dust is not raised, and wash the hands immediately 
after handling anything likely to be infected. (The application of white 
oil to blankets and spindle oU to floor boards is employed in some hos- 
pitals to reduce dust.) 

When collecting sputum cups, gloves should be worn. Sputum is 
generally dealt with by a porter or orderly. It is sterilized baorc it is 
emptied into a drain. The cups are sterilized and returned to the ward. 
If any sputum is upset it should inuncdiatcly be wiped up with swabs 
wrung out of a strong antiseptic. Receptacles for specimens of sputiun 
should be labelled before they are handed to the patient. 

Patient’s handkerefarfs. Paper ones should be collected into a paper bag 
and biumt. Cotton ones are collected into a pail containing disiiffectant. 
These are then taken to the laundry where they soak for some hours 
and are boiled before being washed. 

Hospital Rules. Nurses should make themselves familiar with the 
hospital’s rula for the proper method of collection and disposal of 
soiled dressings, dust sweepings, ward rduse and waste food; for the 
specif treatment of all articles used such as thermometers, instruments, 
utensils, linen and bedding; the routine care eff idl fixtures and fittings 



BINTO ON HYOIENE TO NURSES 497 

including sinks and drains; and for the care of domestic appliances 
such as brooms, brushes and dusters. These rules should be conscientiously 
kept, they have only one object — the prevention of infection. 

Ward maids and other domestic workers employed in a sanatorium 
should be taught scientific methods of sweeping, dusting and cleaning 
and the proper care of all the articles they use. They should understand 
how infection is conveyed and the measures laid down for the prevention 
of spread of infection. 

Nurses* Health. Nurses undergo a physical examination before they are 
accepted for training in a sanatorium. This examination includes an 
X-ray examination of the chest, and Mantoux’s test (see p. 486). Further 
to this the nurse will be expected to report minor ailments such as colds 
without delay so that she may be excluded from duty if the physician 
considers this advisable. She should attend for record of her weight 
at regular (usually monthly) intervals, and she will be submitted to 
regular periodical X-ray examination of her chest. 

The maintenance of the general health of the individual is of primary 
importance in resisting infection to tuberculosis. Nurses will find that 
they are provided with good food — three meals a day with snacks in 
between meal times will be so planned that nurses are never on duty 
on an empty stomach. Nurses must eat their meals and never go on 
duty fasting. They must always wash their hands before meals and 
not eat anything in the wards. 

Good living conditions, airy bedrooms, pleasant dining rooms and 
sitting rooms, recreation^ facilities, provision for adequate rest and 
good teaching and studying facilities will all be provided. Leisure should 
be wisely used for healthy recreation and occupation and nurses should 
keep reasonable hours. Friendships with patients should be avoided. 



Chapter 32 

Examples of Diseases of the Skin 

Introduction — Characteristics of skin lesions — Exan^Us of rum-spec^ conations: 
Urticaria — Eczema — Psoriasis — Diseases due to rmctobic injection, vegetable fungi 
and animal parasites-^ImpeHgo — Pemphigus — Lupus — SeborrhoeaSycosis — Sca- 
bies — Pediculosis — Ringworm — Athlete's foot — Faous — Herpes 

T he skin has many functions. It covers and protects the supportii^ 
structures of the body, prevents the entry «jf micro-organisms and 
assists in the regulation of the temperature of the body. It has a 
slight respiratory action, eliminating a sm^l quantity of COa, and is an 
important excretory factor in that it eliminates water and salts in solution, 
fatty acids and cholesterol. It has .slight absorptive faculties. 

The skin has also an important psychic function; developed, as it is, 
from the same elements as the nervous system, it responds to emotional 
states, and expresses emotions of fear, shame, anger, pleasure, &c., and 
it is this intimate association of the skin with the functions of the nervous 
system that makes the care of patients with diseases of the skin so very 
important as well as so particularly interesting. 

These patients need very careful consideration in order to make them 
feel that they are really wanted, and that they are going to be cared for 
and helped to overcome that dreadful attitude of mind in which they 
imagine themselves to be deformed, and think that people consider them 
infectious, with consequent development of a tendency to hide not only 
their disability but themselves, and often to refuse to appear in public. 

Patients with diseases of the skin are always very thoughtful and grateful 
and make a display of gratitude for even the slightest consideration which 
is almost embarrassing to the recipient of it. 

The symptoms of diseases of the skin are divided into subjective — 
which the patient complains of — such as burning, itching, tingling, heat 
and, more rarely, pain. The objective symptoms are those which can be 
discovered on examination. The lesions most commonly seen in skin 
disea.ses are divided into primary and secondary lesions. 

The primary lesions are: 

A macule, which is a slight discoloration of the skin, an example being 
seen in the rash of measles. A freckle is a macule — ^it is not raised above 
the level of the surface of the skin. 

A weed is slightly raised; it may be a blotchy patch, or a line or streak; 
it is raised because the skin is swollen. An example of this is urticaria. 

A paptde is a little raised elevation, like a pimple. A tudule or tubercle 
is a large papule, as seen in lupus and in the tertiary stage of syphilis. 

A vesicle is a tiny sac of fluid, which may surmount a papule or appear 
on the skin independently of any other lesion. A bulla is a large blister 
or bleb containing fluid. 

A pustule is a similar little sac filled with pus. 

498 



mSBASES OF THX SKIN 499 

A scale is produced whm air gets between the layers of the skin, causing 
it to separate as do the scales on fish. This lesion is seen in ichthyosis and 
psoriasis. 

The lesions described as secondary are produced by the irritation of 
some discharge or exudate or by injury to the skin, often by scratching. 
These lesions include: 

Crusts, such as arise during the healing stage of a papule; and (in the 
case of the other examples below) when the top has been knocked off a 
lesion or when it has been made to bleed. A crust consists therefore of 
dried serum, blood or pus. 

Excoriation is usually due to scratching. Pigmentation may be due to the 
same cause; or it may be produced by the presence of constant moisture, 
or may be left after crusting has occurred. 

Ulceration and erosion are due to destruction of the superficial tissues. 

Scars are left as the result of healing by the formation of fibrous tissue. 

Rhagades or fissures appear as splits or cracks in the epidermis, exposing 
the dermb which lies beneath. These are often the result of excoriation 
either by scratching or from constant contact with an irritating discharge 
or exudate. 

Examination of the skin. Examination should take place in good 
daylight; artificial light is not to be recommended. The whole of the 
patient’s body should be exposed for examination so that both sides of it 
can be seen at once. The area of distribution of the lesion should be carefully 
observed and note taken as to whether it is symmetrical or asymmetrical 
and also where the lesion is most marked, and whether it exists only on 
certain parts, such as the flexor or extensor surfaces of the limbs. The type 
of lesion should be determined, as to whether it is composed of wheals, 
papules, macules and so on; or whether the condition seen is multiform 
in character. The colour of the rash and of the remainder of the skin should 
be considered and the condition of the hair follicles and the pores. The 
lesion should be felt to discover whether it is hot or cool, and whether the 
skin is swollen. 

The history is important and should include the patient’s age, address 
and occupation. For example, a nurse may get a skin reaction firom using 
antiseptics, and bakers develop a well>known trade dermatitis. 

The patient should be asked whether he has any relatives who are simi- 
larly afflicted, as in the case of some of the non-specific skin diseases there 
may be an hereditary tendency to such. In the case of the specific skin 
diseases there may be a history of contact for example with cases of scabies 
or impetigo. 

Another series of questions includes those which would elicit the exist- 
ence of any emotion^ stress or strain, anxiety, or nervous tension. The 
patient should also be asked whetho- he is taking any medicine, and the 
prescription should be looked at to note whether it contains any drug 
which might cause a rash. For example, potassium bromide may produce 
a pustular rash, particularly on the face and shoulders; sulphur may cause 
a local or geiM»^ dermatitis while both arsenic and belladonna may cause 
an erythematous rash. 

The urine should be tested, as eczema may be associated with glycosuria 
cMT^albuminuria. The general condition of the patient should be observed — 
he may ^ fat or thin, may appear nervous and fidgety or be phlegmatic. 



500 DlSEASXfi OF THE SKIN 

The p>atient should be aidced what he complains of, and if he says 
‘itching’, he should be asked whether this is worse when he gets into bed* 
He should also be asked whether the partaking of any particular foods or 
any special set of circumstances makes the lesion worse and whether he 
has noticed any treatment or other conditions which may have seemed to 
relieve it. 

The causes of skin diseases are numerous, and may be divided into 
^cific and non-specific conditions. The majority will be found to be in 
the group described on p. 501. 


POINTS IN THE NURSING OF DISEASES OF THE SKIN 

Treatment and nursing. A patient with a skin disease — let it be 
repeated — ^must be made to feel that he is going to be cared for. It is a 
very good plan, if the physician will permit it to be done, to bath the 
patient at the outset in some emollient bath, such as oatmeal; by this 
means the whole of the patient’s skin can be thoroughly examined and he 
will feel he is really being well attended to. He can then be put to bed and 
should be given a hot drink and tucked up and made to feel happy, cheer- 
ful and contented as he looks forward to his future treatment. 

A nurse requires to be tactful and gentle always; she considers the feel- 
ings of her patient in the nice way she performs routine nursing duties 
for him; she must stress this attitude more in caring for patients with skin 
diseases, as they are so very sensitive about their condition, and may con- 
jure up convictions that people are being impatient with them, or think 
they see a flicker on the face of the nurse which, though it really means no 
more than that she is preoccupied for the moment, makes them imagine 
that she feels disgust at attending to them. In these instances particularly 
she must develop that habit of attending only to one patient at a time, 
and of giving him all her thoughts as well as her actions, for the time being. 

In the treatment of skin diseases rest is just as important as it is in the 
treatment of a broken leg. Rest in bed is usually ordered at the commence- 
ment of treatment; but, even if this is not so, means will be taken in an 
ambulatory case to protect, and prevent irritation of, the affected area. 

Speaking generally — it^amed lesions which are hot and tense are treated 
by the application of cooling lotions, the dressing being kept wet; oint- 
ments cannot be used on a hot skin, as these substances contain fat which 
prevents radiation and makes the skin condition worse. Powder should 
be used in such a case. 

For moist lesions either powders or pastes are used. A paste contains a 
great deal of powder, and moisture can penetrate this and thus be removed 
from the lesion. Calamine liniment is an oily preparation which is soothing 
and protective, and is used for subacute cases. 

A scaljf lesion must be freed of scales; crusts and scabs have to be removed 
before treatment can effectually be applied to the lesion which lies 
beneath. 

Chronic skin diseases require stimulating dressings; but very mild prepara- 
tions will be used at first, and observation of the effect will be made 
before the stren^h of the application is increased. 

Cleansing the skin is important at all times; but the use of water is in some 
cases questionable. It is used for removing scales in psoriasis; but, when 



NURSING OF DISEASES OF THE SKIN 5OI 

the skin is hot and inflamed, soap and water act as an irritant, except in 
BO &r as water is applied in the form of some evaporating lotion. 

Weeping lesions are usually cleansed by means of paraffin or olive oil, 
though in some instances normal saline is employed for this purpose. 
In most chronic skin lesions, or those which are covered with crusts and 
scabs, either olive oil or starch poultices are used. 

The baths which are commonly employed in the cleansing of subacute 
and chronic skin cases are emollient baths, containing either a pound of 
borax, from 2 to 4 pounds of bran or oatmeal, or from i to 2 pounds of 
starch to a bath of 30 gallons of water. 

Antiseptic baths employed are from 2 to 4 ounces of sulphur, used in 
parasitic conditions, such as scabies; and Condy’s fluid, a pale pink 
solution being employed, not strong enough to discolour either the 
patient’s skin or the bath. 

Observation is very important. It is impossible to state how this can be 
carried out, and it must be sufficient to say that a nurse, who is handling 
a patient daily, should be the first to note whether a treatment is suiting 
a lesion or not, and that she should be able to formulate and express what 
she has observed, and to report fully to the physician as soon as possible. 

General treatment. Enough has already been said to help the nurse 
to realize that the wellbeing of a skin lesion may depend to a very great 
extent on the absence of nervous tension, anxiety and emotional disturb- 
ance. A patient’s mind must be at rest, whether it is considered necessary 
to rest his body by keeping him in bed or not. Any indigestion, constipa- 
tion, sleeplessness, ren^ disorder or disorder of menstruation should be 
investigated and treated, as it may have a bearing on the cause of the 
disease. The presence of septic foci should be considered and treated. 

The bedclothes must be smooth and even, and non-irritating; tlie cloth- 
ing the patient wears next to his skin may be of silk or cotton, but not of 
wool. 

The bow'cls should be kept acting regularly; but if aperients have to 
be employed these must be judiciously chosen. Unless a nurse knows 
exactly what a particular doctor prefers in certain cases, she had better 
refer this matter to him. 

When drugs are employed the nurse must observe their effects, and the 
same applies to the administration of vaccines and glandular extracts. 

Diet may not have to be considered in many cases, but in some it will 
be an advantage to avoid all highly seasoned foods, stimulants such as 
alcohol and coffee, excessive use of sugar or heavy protein food. Plenty 
of bland drinks and water should be given, and careful note is always to 
be made of the effect any particular food is found to have on a patient. 


EXAMPLES OF NON-SPECIFIC DISEASES AND INFLAM- 
MATORY LESIONS OF THE SKIN 

Urticaria. This condition is usually acquired, because the patient has 
some idiosyncrasy to a given set of circumstances — to the pollen of some 
plant, of to some particiUar food, e.g. shellfish, or any other fish, sometimes 
being the determining cause of an attack of urticaria. The administration 
of horse serum in the treatment of disease is very frequently followed by a 
reaction which is characterized by an urticarial rash. 



50 a DISBASBS or tbb skin 

Acute urticaria is characterized by weals and swollen patches which are 
red at first, the vesicles alterwards becoming blanched and the patdi 
turning white. If this occurs on the mucous membrane of the throat it may 
be dangerous, as asphyxia may be catised. As a rule, this form of urticaria 
can be relieved by foe administration of from 5 to lo minims of adrenalin, 
given by hypodermic injection. 

The acute form of urticaria tends to become chronic. The patient is 
constantly covered with netderash, and this is so irritable that it prevents 
his sleeping. He may have a few days of freedom firom the irritating 
condition, but it reexus and may continue at intervals for months or even 
years. It is difficult to find a cause for this type, which sometimes seems 
to be associated with distress or emotion, though frequently there is no 
such apparent association. Treatment is very difficult. 

Eczema occurs in many forms, and trade dermatitis is one of these which 
is usually produced by some external irritation. Baker's dermatitis is due to 
handling flour; surgeons and nurses may get dermatitis from foe use of 
antiseptics. The use of irritating clothing and soaps is another cause, and 
it may also be associated with disorders of foe endocrine glands or with 
disorders of metabolism. 

Eczema is described in three main forms — acute, subacute and chronic. 
It may be extensive or localized and it may be present in an acute form 
on one part of foe body and in a chronic form on other parts. 

The symptoms present in eczema are various— The part may be 
red and hot to the examining hand, and this is due to dilatation of the blood 
vessels. As a rule this symptom passes on to swelling of the affected area and 
the skin may pit on pressure. 

Weeping is the term used to describe the presence of an exudate; blood 
from foe vessels, which passes into the epidermis and dermis, separates 
foe epidermal cells, and laJcelets of fluid collect between the cells. This 
forms vesicles on the surface of the skin, and serum oozes out — a condition 
known as weeping eczema. 

Crusting occurs when fluid which contains debris rests and ’dries on foe 
surface. 

Scaling is due to hewing up on the surface of imperfectly formed epider- 
mis. This is quite different from crusting. 

In foe treatment of eczema foe symptoms which are present are 
dealt with. If a cause b known it should be considered. The main points 
in foe treatment as regards local applications arc: First to protect foe skin 
so that it can have rest, and to sec that all aggravating substances, includ- 
ing soap and water and the use of any irritating coverings, arc eliminated. 
The next point b to relieve the skin of all irritation — patients must not be 
allowed to scratch and some means should be taken to prevent fob. 

The following substances are included amongst those which will often 
be ordered. 

In acute eczema lotions which cool and relieve congestion will be em- 
ployed, such as lead and glycerine. The affected part should be kept wet, 
a fairly thick layer of matei^ being used which will retain mobture; foe 
nurse should keep wetting fob, but foe must take care foat foe p^ 
undeigoing treatment does not btxome chapped. If fob happens, calamine 
cream or paste will be used instead. 



NOK>8raCtFtC DISEASES 503 

In the subacute form, pastes will be employed. Lassar’s paste is an oint- 
ment with a good deal of powder in it; it contains zinc and starch, salicylic 
acid and Some ointment base, such as vaseline. The amount of powda: 
that is present p>ermits the paste to take up the exudate from the sur&ce 
of the ieaon and allows it to pass through the paste instead of being con- 
fined underneath the dressing as it would be if an ordinary ointment were 
used. As a rule an application of paste is made twice a day, but it is 
important to clean ojff one application by means of liquid pau'affin or olive 
oil before a second application is made; if this is neglected, it means that 
paste will be put upon paste and a mass will accumulate on the surface 
of the lesion. 

In chronic eczema stimulating applications are employed. Ointment or 
paste may be used. C!oal tar preparations are applied and X-ray treat- 
ment used in order to help the cdls to return to their normal character. 

Psoriasis forms a rather large percentage of the non-specific skin 
diseases. It tends to run in families, and it may begin early in life and the 
patient never again be fi'ce. He may have one attack, be treated, find it 
clears up and never have another. It may commence in middle age or 
old age; no age is free from the onset of psoriasis. The cause is not known. 

The lesion and the distribution is characteristic; in most cases the knees, 
elbows and scapulae are the sites commonly covered. The lesion begins as 
a red patch with a heavy scaly surface; the scales split and air between 
them gives the silvery appearance which is so well known. 

Many forms of treatment are tried, in some cases with success. Before 
treating the lesion it is necessary to remove the heavy silvery scales by 
warm baths, containing lysol, using a nailbrush and coal tar soap to scrub 
the scales off. They will reform, but in the interval treatment can be 
applied. Amongst the substances used are wood tar, oil of cade, salicylate 
ointment, chrysarobin, ultra-violet light and X rays. 

SOME OF THE COMMONER SKIN DISEASES WHICH ARE DUE 
TO MICROBIC INVASION. VEGETABLE FUNGI AND ANIMAL 

PARASITES 

Impetigo is a very common affection of the skin in the case of children, 
due to the presence of pus-producing organisms, staphylococci or strepto- 
cocci, and characterize by blisters on the skin, the fluid in the blisters 
becoming pus which in a few days dries up and forms into crusts. The 
lesions occur most commonly on the face, head, arms and legs. 

Impetigo frequently occurs as a complication of scabies and pediculosis, 
and may begin by septic infection of a scratch or abrasion of the skin. 
The disease, which usually terminates within a fortnight, is very contagious, 
especially amongst children, and care must be taken to prevent spread of 
infection. 

When a child with impetigo is first seen, his face may be covered by 
blisters, pustules and scabs. 

Treatment. All crusts must first be removed by bathing them with borax 
and water, or by applications of olive oil or starch poultice. When soft 
they can be picked off with forceps and the area cleansed with a weak 
antiseptic loticm and gently dabbed dry. Watery solutions used as loc^ 
applications include aniline dyes such as acriflavine, gentian, violet, bril- 
liant green, and mercury. Ointments are not used, but Lassar’s paste, 



504 DISEASES OF THE l»UN 

which contains zinc and to which a per cent, atnmoniated mercury 
may be added, can be employed. 

Sulphonamides such as M & B 693 may be given orally for a week, 
and sulphathiazole may be applied locally. 

Ail fresh scabs which form must be removed before each fresh applica- 
tion. As a rule the condition clears up in a week to 10 days. Slight discolor- 
ation will be left but this will disappear in a few wedts. 

The child’s feeding and toilet utensils should be kept separate, and he 
should not be allowed to play with other children unless the affected 
parts are covered. It is important to try to discover any underlying 
cause of impetigo, and if the subject is debilitated a good nourishing diet 
and a change of aiir will be beneficial. Impetigo may be complicated by 
adenitis of the local lymphatic glands, and in a severe case suppuration 
of the glands might occur. 

Pemphigus is a skin disease characterized by the formation of blebs 
and bullae, which become purulent and rupture, and form crusts. It is 
due to several organisms including staphylococci and streptococci. It 
may be present in the newly bom, when it is thought to be a mamifestation 
of syphilis. An acutely infectious form may occur in adults, or a more 
common form, which is less infectious and is described as pemphigus vulgaris. 
The treatment is similar to that described for impetigo. 

Lupus vulgaris is a skin affection produced by the tubercle bacillus. 
It begins early in life and usually appears first on the cheeks and nose as 
small red patches which spread very slowly xmtil they form a reddish scar. 

The treatment is selective, in order to damage the bacillus. Ultra-violet 
light treatment is employed both locally, and generally to the whole 
body. 

In addition any lesion such as suppuration of the glands of the neck, 
which may be giving rise to infection of the skin of the face, should be 
treated. The general treatment described in the case of pulmonary tuber- 
culosis is also applicable to cases of lupus. 

The resxUt of lupus may be extensive scarring and contraction of the 
skin as the result of tissue destmetion. 

Septic infections of the skin, occurring as boils and carbuncles, are described under 
the heading ‘irfection’ on p. 557. 

Seborrhoea is inflammation of the sebaceous glands, which are most 
numerous on the scalp, resulting in excessive secretion of these glands. It 
usually responds to cleansing of the surface and keeping the head free of 
scurf. In some cases salicylate and sulphur preparations are employed. 

Sycosis is infection of the hair follicles by staphylococci, and it occurs 
in children on the scalp and in men on the chin. In a few cases infection 
is general and the axillary and pubic hairs and eyebrows are affected. 

Epilation of the infected hairs is carried out, and great care must be 
exercised to prevent reinfection. Men have to be particularly careful, 
when shaving, to cleanse the skin 'with spirit and to sterilize the razor 
carefully. 

Scabies is due to the presence of a tiny parasite, the itch mite— otam 
scabiei. The female burrows into and eats her way through the homy 
layer of the epidermis. She is a cold-blooded animal aiKl works best when 
the skin is warm and the patient is in bed at night. She lays her c^gs as 



COMMONER SKIN DISEASES 5O5 

biirrows and also secretes an acrid fluid which irritates the skin and keeps 
the patient awake and scratching. 

The burrows are about J inch long, and the margins are rough and 
may collect dirt, so that they often appear as dark streaks. The eggs 
hatch in about 3 days and become adult mites in a week. The young 
emerge when the body is warm, which is another cause of irritation and 
scratching. 

Scabies affects the skin of the hands and wrists, at the sides and webs 
of the fingers, the axillary folds, backs of the knees, elbows and buttocks. 
The lesions are papules, vesicles and pustules. Scratching may result in 
impetigo. 

A history of severe itching which is worse at night would always suggest 
the possibility of scabies. The cure of scabies is quick and sure — the eggs and 
insects are susceptible to benzyl benzoate and sulphur. 

Treatment consists in (i) breaking up the roofs of the burrows to expose the 
itch mite’s eggs, by washing and scrubbing with soft soap and (2) the 
application of an acaricide^ either benzyl benzoate emulsion or sulphur oint- 
ment may be used. 

The patient is soaped all over with a green soft soap rubbing it well into 
all parts which itch, he gets into a hot bath and continues to rub and 
scrub with a soft brush for twenty minutes. The skin is dried and an 
emulsion of benzyl benzoate, 25 per cent, made up in water with 2 per 
cent, lanette wax, is either rubbed in or painted on all over the body, 
except the face and head, paying special attention to the itching areas. 
During this time the patient’s underclothing is steam-disinfected ready for 
him to put on again. The local sanitary authorities disinfect his bed cloth- 
ing and return it to the house before night. Some authorities consider one 
or two treatments effective but the majority think it better to advise the 
patient to rub the emulsion in all over the body morning and night for 
three consecutive days. On the fourth day he takes another hot bath to 
rinse off the emulsion and puts on clean clothing and has his bed clothing 
changed. 

Prevention of infection and reinfection is very important, and all members 
of a household in which a case of scabies occurs should be questioned about 
itching. Anyone who has shared the same bed as the patient should be 
treated at the same time. 

Pediculosis may affect the head, body and pubis, axillae and eye- 
brows. Pediculosis capitis. The head louse or pediculus capitis is a small grey 
parasite; it infests the hair of the head and the female lays about 50 eggs, 
called nits, which are deposited on the hairs close to the scalp, by a sticky 
Wm. Thpe eggs hatch in about a week. The movement of lice in the hair 
is irritating and the patient scratches his head in order to obtain relief. 
Sores may be produced by scratching and these may be infected which in 
a serious case would result in enlargement of the lymphatic glands in the 
suboccipital region of the head. 

The treatment has been described in the cleaning of a verminous head 
on p. 50. 

Pediculosis corporis. The body louse or pediculus corporis is slightly 
larger than the head louse. It lives in the seams of the clothing which lies 
next to the body. This condition is met in dirty people and those who arc 
debilitated and neglected. The female louse lays her eggs in the scams of 



5o6 diseases of the skin 

the clothing; they hatch in from 2 to 3 weeks. The lice biting the skin 
cause itching but when examining the patient they are not found on the 
skin, but on the clothing. 

Treatment The clothing, bedding and blankets should all be disinfected. 
The patient should have a disinfectant bath and a healing ointment 
should be employed to heal any injuries produced by scratching. 

Pediculosis pubis. The pediculus pubis is shaped rather like a ladybird. 
It is a dirty grey colour. It has claw-like processes attached to some of its 
legs by which it clings closely to the pubic hairs. The female lays about 
15 eggs. This parasite may spread to hairs on the skin of the abdomen 
and also to the eyebrows and eyelashes. 

It is very unlikely that a nurse will see pubic lice, but the presence of 
little greyish spots over the pubis and the skin of the lower part of the 
abdomen should arouse her suspicions and then she should get some more 
experienced person to look at the patient. 

Treatment, The hair of the affected parts should be shaved off and burnt; 
an ointment containing 10 per cent, mercury should then be rubbed well 
into the parts. After some hours the patient may have a bath or be Viathed. 

When the eyelashes are affected the parasites must all be picked off 
with forceps and yellow oxide of mercury 2 per cent, applied. 

The clothing should all be disinfected. 

Ringworm is due to a vegetable organism of a similar class to that 
which forms fluff on jams, &c. Ringworm attacks the skin and its appen- 
dages, the hair and nails. 

Ringworm of the scalp or tinea tonsurans is a fairly common and very highly 
contagious disease in children. The fungus attacks the hair, which breaks 
off; the skin of the affected area of the scalp is covered with debris and 
scales, and it may be slightly reddened. The area is often circular in out- 
line, and the disease spreads until a large area may be affected. 

The modern treatment is by means of a carefully graduated dose 
of X rays. The skin of the scalp should be well washed with soap and 
water, the hair cut short for an area around the affected part, and the 
scalp cleared of debris and scales. The X-ray treatment is then given, 
and the patient is afterwards kept under observation; his head is washed 
with soap and water daily, and after the eighteenth day the affected hairs 
fall out. The hair will grow again in from two to three months. 

Isolation of the patient is necessary, particularly from other children, 
and when nursed in a ward his toilet and feeding utensils should be kept 
separate, and his head covered by a clean linen cap. 

Another modern treatment of ringworm is by the administration of 
thallium acetate^ a very carefully graduated dose of the drug being ordered 
as it is highly dangerous. 

Ringworm of the body — tinea circinata — and of the groins — tinea cruris — 
attacks the skin. A red patch appears w^hich spreads until a fairly large oval 
lesion is formed; it may be surrounded by a ring of vesicles. Lesions occur 
on the forearms and neck. 

As the lesion is on the surface of the skin it is easy to cure and will 
respond to antiseptics such as aniline dyes, mercury and iodine. The 
patient’s toilet articles should be kept separate until the condition is cured. 
The patches should be covered, so that the patient’s clothing is not 
infected. 



COMMONER SKIN DISEASES 507 

Tinea barbae requires the same treatment as ringworm of the scalp. 

Athlete^ s foot is contracted from swimming pools, baths, and the floors 
of gymnasiums, contaminated by infected feet. It is a form of ringworm. 
The lesion, which appears as white skin between the toes, very quickly 
responds to cleansing with a mild antiseptic and painting with iodine. 

Favus is also a vegetable fungus; it is rarely seen in England. It affects 
the scalp mainly and most commonly of children. The condition begins 
as little yellow follicles, and as it spreads large yellow honeycomb-like 
masses exuding pus form on the scalp. 

The treatment consists in removing the masses by the use of spirit lotion 
and salicylate ointment. X-ray treatment is employed, as in the case of ring- 
worm. 

Herpes zoster is inflammation of the posterior primary division of one 
or more spinal nerves. It affects the intercostal nerves or any spinal nerve 
and in some cases the fifth cranial nerve. 

The condition is thought to be due to a filtrable virus. It is considered 
to be associated with chickenpox though little is known about its exact 
relationship. 

The symptoms in herpes zoster are pain and tingling over the course 
of the nerve affected, the area becomes tender and red and after a few 
days crops of vesicles appear along the course of the nerve which is in- 
flamed. After several days the vesicles dry off and separate but the skin 
continues to be tender and painful and in some cases remains hyper- 
sensitive for months. 

The local treatment is to keep the vesicles dry by applications of slightly 
astringent powders or to keep them covered by collodion. It is important 
to prevent secondary infection. Any dressing used as a covering should be 
lightly applied because the skin is very tender. The affected part should 
be kept at rest; in the case of an affected ulnar nerve the arm might be sup- 
ported in a sling. But in intercostal cases the patient should be kept in bed. 

Geiural treatment consists in rest in bed if the temperature is raised or if 
the patient is very uncomfortable and fatigued owing to loss of sleep. 
Aspirin is ordered for the relief of pain, and the diet should be nourishing 
and the bowels kept active. Considerable debility follows an attack of 
herpes zoster and therefore a good convalescent period should be arranged. 

when the pain persists after the attack, painting the affected area with 
belladonna may help; applications of heat ai’e useful in some cases, in 
others electrical treatment or X-ray treatment may be ordered. 

Herpes simplex, although not associated with herpes zoster, is also 
considered to be due to a filtrable virus, which in this case is known to 
be of a kind that will produce encephalitis in rabbits. 

An attack of herpes simplex often occurs on the face, and round the 
nose and mouth of persons who are subject to it, and one attack predis- 
poses to others. It also occurs at the onset of some of the febrile diseases, 
as in pneumonia. 

Herpes begins with tingling sensations in the affected part, followed by 
neuralgic pain and the eruption of a crop or crops of vesicles, which dry 
up in about a week. The eruption may be prevented by dabbing the parts 
with alcohol or with a mixture of tannic acid and methylated spirit every 
half-hour. If not so treated, when the eruption has formed the vesicles 
should be kept dry. 



Section 5 

Gynaecological Conditions and their Treatment 
and Nursing Care. Venereal Diseases. A Short 
Account of Pregnancy, Antenatal Care and 
the Puerperium 


Chapter 33 

Gynaecological Nursing, Preparation for Operation 
and Post-Operative Care 

Introduction — Common gynaecological operations — Notes on preparation and post- 
operative care in vaginal and abdominal cases — Examination of a patient and some 
special treatments including the toilet of the vulva, insertion of tampons, packing the 

vagina and the use of pessaries 

T here are certain points to be considered in the nursing care of 
gynaecological patients both as regards the general condition of the 
patient, and in regard to the organs affected, which include the 
vulva, perineum, cervix, uterus, fallopian tubes and ovaries. It is essential 
that nurses should have some idea of the anatomy and physiology of these 
organs and also of the relation of the bladder to them, which accounts 
for the fact that micturition is so commonly affected in these cases. 

The majority of the gynaecological cases met with in the wards of a 
general hospital are wives and mothers, and in this dual capacity they have 
often led self-sacrificing lives and may have put up with some abnormal 
condition of the organs of generation, and suffered painful and otherwise 
distressing symptoms for a considerable period, and have only consented 
to leave their homes and families for the necessary treatment after con- 
siderable persuasion and at a time when they arc in a very low state of ner- 
vous tension. 

In many cases the general condition may be poor, with repeated bleed- 
ings and profuse menstruation, giving rise to anaemia; in many more 
instances these patients will be found to be losing their courage, they will 
be apprehensive and introspective, they cry easily, and are very readily 
upset by even the slightest imagined unkindness or slight. They arc 
inclined to talk a great deal about their own symptoms and take a morbid 
interest in the symptoms of others; another point is that in some cases they 
may have been in hospital before and are apt to be exacting and talk 
quite openly alx>ut what they were accustomed to, they say, elsewhere, 
and what they think they should be having as treatment now and are not 
having. This type of patient will be found to take advantage of a junior 
probationer and work on her feelings, whereas a more senior nurse would 

508 



GYNAECOLOGICAL NURSING 509 

treat her sensibly, and gently laugh her out of her imagined grievances. 
Young nurses going to these wards should learn to realize that the 
emotional condition of these patients is temporarily abnormal. 

The treatment of gynaecological patients must be kind and sympathetic, 
yet at the same time cheerful and happy and confident and firm. Many 
patients will tend to relax, and behave as if they are more helpless than 
they really need be in the circumstances; but the nurse should remember 
that when a patient acts like this and perhaps demands first one thing and 
then another and behaves in an unduly exacting and selfish manner, she 
is often a long-suffering woman who up to now has had to carry on, un- 
relaxingly and uncomplainingly, in her service of others in her own home. 
The nurse who reflects thus will at once appreciate that the attitude she 
notices in her patient is not the woman’s true self, but an inevitable 
reaction following the anxiety which has preceded her ’ admission into 
hospital, and that the best way to meet this attitude is, by kindness and 
generosity of service, gradually to encourage the patient to become more 
and more self-reliant as she becomes more and more used to her sur- 
roundings. 


GYNAECOLOGICAL OPERATIONS 

The operations performed in gynaecology are divided into two 
groups, (i) the perineal and (2) the abdominal group. 

The commonest vaginal or perineal operations include: 

Dilatation of the cervix such as may be performed to cure one form of dys- 
menorrhoea; 

Uterine curettage ^ or the scraping of the endometrium, which is some- 
times performed for the relief of menorrhagia due to an unhealthy 
endometrium, and also to clear away the retained products of pregnancy 
after an incomplete miscarriage, or to obtain a specimen of the endome- 
trium for examination; 

Amputation of the cervix may be performed for chronic inflammation of 
this part of the uterus, in order to relieve profuse leucorrhoea, or to treat 
cervical erosion or cervicitis. This portion of the uterus bleeds very easily 
and very freely and, in order to prevent post-operative haemorrhage, the 
vagina is frequently plugged with flavine before the patient leaves the 
theatre. 

Colporrhaphy and perineorrhaphy, Colporrhaphy is repair of the vaginal 
wall and the surrounding structures and perineorrhaphy repair of the 
perineal bexly. The operations are frequendy combined. When limited 
to the perineum it is described as perineorrhaphy, and the more extensive 
operation is called colpo-perineorrhaphy; this may be combined with ventral 
fixation, and it is for this reason that the skin of the abdomen, and the 
skin over the buttocks at the back, is prepared in addition to shaving and 
preparation of the skin of the vulva and perineal region (see also p. 51 1). 

Vaginal hysterectomy. In this operation the uterus is removed through the 
vagina, the advantage being that there is no external abdominal woimd 
and there is said to be considerably less shock and disturbance to the 
patient. As a rule a vaginal packing is inserted and left in for the first 
48 hours. The skin of the abdomen is prepared and the vagina is prepared 
by douches before operation. 



5 ^^ GYNAECOLOGICAL NURSING 

Other operations include some on the vulva, such as those performed (a) 
to enlarge the vapnal orifice, (b) to open or remove Bartholin’s cyst or 
abscess, (c) to excise the vulva and (d) to remove urethral caruncle. 

Abdominal operations. These include abdominal hysterectomy which is 
removal of the uterus. There axe a number of degrees of this: 

(1) Sub'-toial hysterectomy^ in which the uterus is removed above the cervix 
when the latter is healthy. This operation is commonly performed for the 
removal of the uterus when it is the site of a number of small fibroid 
tumours. 

(2) Total hysterectomy. The removal of the whole of the uterus including 
the whole of the cervix. 

(3) Pan-hysterectomy. The removal of the uterus togethci* with the tubes 
and ovaries. This operation is performed in cancer of the body of the uterus. 

(4) Wertheim’s operation. Wertheim was an Austrian surgeon of Vienna. 
In this operation the uterus is removed and also the ovaries, tubes and the 
whole of the vagina, all the tissue on each side of the vagina and all the 
glands on the wall of the pelv'is. It is performed in cancer of the cervix of 
the uterus. 

Other operations on the uterus include myomectomy^ the enucleation of 
fibroid tumours from the wall of the uterus, when the uterus is stitched up 
again; ventro-fixation, in which the uterus is stitched to the anterior abdomi- 
nal wall, performed in cases of prolapse and in the correction of retro- 
version; shortening of the round ligaments^ performed for retroversion, a pleat 
being put in the ligaments and by this means the uterus is pulled for\\'ard 
and the retroversion corrected. 

Op^ations on the ovaries and tubes include ovariotomy — removal of an 
ovarian cyst; oophorectomy — removal of an ovary; salpingo-oophorectomy — 
removal of one tube and one ovary; salpingectomy — removal of a tube, and 
salpingostomy — the opening of a tube in order to make a new orifice. 

The preparation for operations on gynaecological cases may be similarly 
divided into preparation for (a) vaginal and {b) abdominal operations. 

In preparation for perineal operations^ it is particularly important to bear 
in mind these facts — the rectum must be empty, and it is important to 
note that the administration of an enema five or six hours before the opera- 
tion usually ensures that it will be full. In order that it should be empty 
an aperient may be given 48 hours before the operation followed by an 
enema 24 hours before and, if time does not permit of thus, the enema may 
be given the night before the day of operation so that it has been adminis- 
tered well over twelve hours beforehand, in order to be at all safe. If given 
later the lower part of the bowel may be full of fluid which will be evacu- 
ated as soon as the surgeon begins to manipulate the perineum. 

In preparing cases for vaginal operations in some instances douches are 
ordered, particularly when any vaginal discharge is present; douching 
may be followed by painting the interior of the vagina with some aniline 
dye, and in some instances packing with an antiseptic is also employed. 
The douche given for these cases is a cleansing treatment, and some mild 
antiseptic is usually employed; it is important that, if this douche is to be 
effective, the whole of the cervix should be reached. A nozzle that will reach 
these parts should be used and it should be moved about, in order to direct 
the fluid on to every part, including the vault of the vagina. A further 
point to be considered is that the bladder must be empty. 



OYNAEGOLOOICAL OPERATIONS 5II 

The abdominal group includes operations on the uterus, tubes and ovaries, 
and these do not differ regarding preparation, theatre technique and post- 
operative nursing care from ordinary surgical abdominal cases, except in 
one points — the fact that a mid-line incision fairly low down the abdominal 
wall is employed necessitates that the bladder should be quite empty. 

In order to ensure effective emptying of the bladder in all major opera- 
tions, the patient should be catheterized just as she leaves the ward for the 
operating theatre and it is advisable that the catheter should be left in, 
having a spigot placed in its free end, so that the bladder can be drained 
after the patient is anaesthetized and before the surgeon makes his incision 
or begins to manipulate the parts. 


SHORT NOTES ON THE PREPARATION AND POST- 
OPERATIVE CARE IN SPECIFIC CASES 

Dilating and curettage of uterus- -InsuflBation of 
fallopian tubes. 

Preparation, An aperient is given two days before, the vulva and perineal 
area are shaved, but no skin preparation is necessary. The patient may go 
to the bath after shaving, and there is no need to pass a catheter provided 
the patient passes urine before she is anaesthetized. 

Post^operative care. The patient may be given two pillows and an air- 
ring cushion as soon as she comes round from the anaesthetic. A sterile 
pad should be worn and careful watch made for any bleeding. The toilet 
of the vulva should be carefully performed whenever the patient passes 
urine and faeces. It is particularly necessary to dry both perineum and 
vagina before a pad is applied. In many hospitals it is routine practice for 
the patient to be given 30 minims of ergot twice a day for 48 hours or until 
ble^ing ceases. Provided bleeding is not excessive, the patient may have 
a bath 24 hours after the operation. She may be given an aperient on the 
second day. She may wash herself and sit out of bed on the day after 
operation and may go home as soon as she wishes. Hospital cases are 
usually discharged on the sixth day. 

Perineorrhaphy and amputation of cervix. These operations are of 
a rather more serious character. 

Preparation, An aperient is given two nights before the operation, and 
the patient is shaved over an area extending from the sternum in front 
to the same level at the back, shaving right through the whole of the 
perineal and vulval regions. The same area is treated by an antiseptic, 
one of the aniline dyes being most commonly used. A catheter is passed 
just before the patient is taken to the theatre, and left in position until 
the patient is in the theatre, when the bladder is emptied by removing 
the spigot. 

Postoperative nursing care. On receiving the patient back to bed she is 
given a knee pillow and a sterile pad is kept in position by a T bandage. 
She is nursed in the scmirccumbent position and may have as many as 
three pillows for her head and shoulders and an air ring under her but- 
tocks. The temperature is recorded morning and evening. Until she is 
round from the anaesthetic it is advisable to nave her knees tied together 
to prevent any separation of the legs by violent involuntary movements 



5 1 2 OYNAEGOLOOIGAL NURSING 

with consequent strain upon the perineal region. The most important point 
in the post*operative care of a case of perineorrhaphy is keeping the sutures dry and 
so preventing sepsis. This may be secured by frequently changing the 
dressing and catheterizing the patient until she can pass urine without dis- 
comfort; then, when she is able to pass urine, the perineal dressing must 
be attended to each time (see note below). 

After the operation the patient is usually allowed to sleep off the effects 
of the anaesthetic. Early on the morning following the operation the 
perineal dressing is performed for the first time and the patient is catheter- 
ized. The gauze dressing or sterile pad which is kept in position by means 
of a T bandage is removed, the parts are gently cleaned by swabbing 
with perchloride of mercury 1/3,000. It is very important that, in clean- 
sing the labia of patients whom it is necessary to catheterize over a period 
of a few days or a week or so, the nurse must never wipe the parts with the 
swab, as this removes the surface epithelium and results in marked sore- 
ness which may give rise to sepsis. Swabbing should be performed by 
dabbing movements and not by rubbing or wiping. The catheter is then 
passed, the stitches are dabbed quite dry with a little alcohol or spirit 
lotion or by using dry swabs, and a clean dressing is applied. Before the 
bandage is reapplied, the patient is turned over and the routine treatment 
of the back — washing, rubbing and powdering — is performed. When regu- 
lar catheterization is employed it is usually performed every 8 hours; and 
when the patient is able to pass urine voluntarily it is a good plan if she 
can be persuaded to do so at regular intervals — every 4 or 6 hours — and 
then the routine treatment as described above is carried out each time. 
The interior of the vagina should be dried carefully as in patients lying in 
bed it forms a cul-de-sac where urine can collect. The same careful treat- 
ment is necessary after the patient has had her bowels moved. Some sur- 
geons like their patients to have a urinary antiseptic such as hexamine, or a 
mild diuretic such as potassium citrate. In some cases both treatments 
arc employed. 

This particular care of the perineum is carried out for from 7 to 10 
days or until the stitches are removed. When catgut stitches have been 
employed, this material becomes absorbed during the course of a week or 
so; but when silkworm-gut stitches are used they are generally taken out 
between the seventh and tenth days. 

Retention of Urine, It is important that the bladder should not be dis- 
tended; the collection of more than 12 ounces of urine may affect the tone 
of the bladder for a week. 

Another very important nursing point is the management of the 
action of the patient’s bowels. 

Control of the action of the bowels. Most surgeons consider that it is advisable 
if the bowels can be kept from acting until the third, fourth or fifth day 
after operation, some surgeons going so far as to ensure this by limiting 
the diet to fluids and jellies, avoiding foods which would produce a bulky 
stool, and also giving cool fluids rather than hot in order to avoid exciting 
peristalsis. Other surgeons allow the patient to have any diet that she 
fancies, but in order to ensure that the stools should be soft, and easily 
passed when they do occur, liquid paraffin is administered, either with or 
without the addition of a small dose of phenolphthalcin two or three times 
a day as soon as the patient has ceased to feel the nausea resulting from the 
anaesthetic — if the bowels have not acted by the fourth or fifth day it is 



PREPARATION AND POST-OPERATIVE CARE 513 

usual to give an aperient such as cascara evacuant. If the patient finds 
difficulty in passing stool she must be warned against straining for this 
purpose, as this will tug at the stitches, and advised to wait quiedy until 
the aperient produces its action — ^if she is unduly worried, or if for any 
other reason the nurse considers it advisable to obtain a bowel action 
more rapidly, a warm small olive oil enema may be administered. 

Patients usually get up after perineorrhaphy about the twenty-first 
day and are able to be discharged from hospital two or three days later. 

Vaginal hysterectomy. This operation is occasionally performed 
today and a nurse should know how to prepare the patient. An aperient 
is given two days before the operation and vaginal douches are adminis- 
tered twice a day; some mild antiseptic such as acriflavine i /i,ooo being 
employed. The area of skin prepared is as for an abdominal operation, 
from the sternum to the pubis, the vulva and perineal region also being 
shaved and prepared and the skin of the back as far as the top of the sacrum. 
Some surgeons like the vagina to be packed with gauze soaked in flavine in 
addition to having the skin prepared. 

In the post-operative nursing care the patient is received back to bed recum- 
bent, she has a knee pillow, and her knees are tied together, and she may 
subsequently be nursed in the semirecumbent position as described in the 
post-operative nursing care of cases of perineorrhaphy. It is important 
that the pulse should be observed every half hour for the first few hours 
after operation, and subsequently a four-hourly chart of the temperature 
and pulse should be recorded for the first two or three days. After re- 
moving the uterus the surgeon fills the vagina with gauze packing, and 
he or his assistant will remove this after 48 hours, the nurse preparing 
the necessary appliances and utensils, and arranging the patient in a 
modified lithotomy position on the bed. Once this plug is out the surgeon 
may order douches twice a day or perhaps only one occasionally for clean- 
sing purposes. The patient will probably have difficulty in passing urine 
until the vaginal plug has been removed and she may have to be cathe- 
terized, and this must be carried out with the same care and attention as 
described in the post-operative nursing of perineorrhaphy on p. 51 1. 

The patient will usually be allowed to get up about 10 days after opera- 
tion and she may be discharged from hospital after 14 days. 

ABDOMINAL OPERATIONS ON GYNAECOLOGICAL 

CASES 

The preparation and post-operative care is very similar to that of any 
abdominal operation. In the following notes special mention will be made 
of ventro-fixation and Wertheim’s hysterectomy. 

Routine preparation. All abdominal cases are given an aperient two nights 
before operation, A complete shave is carried out from the sternum in 
front over the skin of the abdomen through the vulval and perineal regions 
up to the region of the waist behind. The skin is carefully prepared, and 
an aniline dye is employed as an antiseptic. Violet green is a good one 
to use as it is powerfully antiseptic and non-irritating, though it has the 
disadvantage of staining the skin. The bladder should be emptied by 
catheterization before the patient is taken to the operating theatre. The 
catheter is usually left in so that the bladder can be evacuated on the 



514 OYNAECOLOOICAL NURSING 

Operating table. A rubber catheter should always be employed for cases 
of Caesarean section. 

In the posUoperative nursing care of abdominal cases, it is usual to insert 
a knee pillow and to give the patient a sterile pad on return from the 
operating theatre. As soon as she has recovered from the anaesthetic she 
may be propped up on two or three pillows and given an air-ring cushion. 
In the opinion of many gynaecologists Fowler's position is inadvisable 
as it keeps the patient too rigidly jvtill in bed, thus provoking a tendency 
to the formation of thrombosis. Free movement is better. In the majority 
of cases a four-hourly record of the pulse and respiration is kept for 36 
hours. Fluids are given liberally as soon as the patient has recovered from 
post-anaesthetic nausea. An aperient is usually given on the second, third 
or fourth night, except in the case of Wertheim's hysterectomy when it is 
delayed for a day or two longer. The knee pillow and ring cushion are 
only permitted for the first few days after operation and should be 
removed not later than the fifth day in order to encourage free movement 
of the legs. Many gynaecologists consider that the provision of a dressing 
after an abdominal operation is not absolutely essential beyond the pro- 
tection of the stitches by means of a sterile towel or a layer of folded 
gauze which can be maintained in position by elastoplast. Other g>mae- 
cologists employ a gauze and wool dressing maintained in position by a 
binder. When clips are employed these are removed about the fifth day 
and, as usual when removing clips, half are taken out on one day (alter- 
nate clips) and the other half the following day. When skin stitches are 
employed these are usually removed about the tenth day. 

Getting up. In the majority of cases, excluding Wertheim’s hysterectomy 
and cases in which complications may have arisen, the patient is allowed 
to sit out on the chair whilst her bed is being made on the thirteenth or 
fourteenth day after operations. She is allowed to get up for half an hour 
on the following evening and may have a bath the next day, and from 
then onwards she is allowed to get up to go to the lavatory until she is 
discharged from hospital a day or two later. 

Ventro -fixation. This operation is performed in order to correct pro- 
lapse and retroversion of the uterus, when this cannot be satisfactorily 
secured by simpler measures. An incision is made in the anterior abdomi- 
nal wall and the uterus is brought up and stitched to this wall. In addition 
to the routine preparation, the vagina should be douched and plugged 
with gauze soaked in some antiseptic, and a perineal compress applied 
as well as a compress over the skin of the abdomen. 

In the post-operative nursing care the patient is received back to bed and 
placed in the same position as any other abdominal case. Care must be 
taken of the toilet of the vulva and perineum whenever the patient passes 
urine. The nurse should watch car^lly the amount of vaginal discharge 
present on the pads which the patient is wearing. In all other points the 
post-operative care is the same as that described above. 

Wertheim’s hysterectomy. The patient is usually admitted at least 
a week before the operation, the bowels arc maintained in activity by the 
use of aperients, and the patient is frequently given a full nourishing diet 
augmented by the administration of 4-6 ounces of glucose a day during this 
time. If she is not sleeping well the gynaecologist will order mild sedatives 
to be employed. The patient’s blo^ will be grouped and arrangements 



ABDOMINAL OPERATIONS 515 

will be made for blood transfiision either before, during or after the 
operation. 

The skin preparation and the preparation of the vulva and perineum is carried 
out as for any other abdominal case. In addition, the vagina is douched 
with a mild antiseptic before the operation and in some cases daily during 
the week the patient spends in hospital. Before the operation the vagina 
is plugged with gauze soaked in some antiseptic. In many instances this is 
performed when the patient is under the anaesthetic and catheterization 
is deferred until this time also. 

In the post-^operative nursing care the patient is carefully carried back to 
bed and the bed is maintained in Trendelenburg’s position by putting the 
foot of the bed on chairs for the first 4 hours after operation. These are then 
replaced by 12-inch blocks, and by midnight of the day the operation has 
taken place — provided the operation was in the morning — the foot of the 
bed may be lowered to the floor. 

The degree of post-operative shock from which these patients suffer 
is very serious, and for this reason all movement should be as gentle and 
infrequent as possible. If the patient is returned to bed on a stretcher she 
should not be rolled for the canvas to be removed — it should be left in 
for some hours and it will do no harm, provided that it is straightened and 
that the patient is not lying on creased canvas. 

Every possible care will be taken to assist recoveiy from shock; the head 
of the bed should be screened in order to avoid draughts, and some sisters 
arrange a little shawl, cowl fashion, around the head to help prevent loss 
of body heat. In many instances the water pillow which is provided in 
the bed contains water at a temperature of 1 18° F. A pillow is placed flat 
against the bedrail at the top — in addition to providing a buffer, it helps 
to maintain warmth as would an eiderdown over the patient. The pulse 
is taken half-hourly during the first 36 hours, and then a four-hourly 
record is kept for several days. 

Routine nursing measures. In addition to the observation of the degree of 
shock and the administration of any treatment that may have been 
ordered such as continuous saline, the patient is left undisturbed until the 
early hours of the morning following operation. At about five or six 
o’clock she is usually catheterized for the first time, the toilet of the vulva 
is carefully performed, the patient is gently turned, the routine treatment 
of the back is carried out and the stretcher canvas which has been under- 
neath her is carefully rolled out and the upper part of the bed is remade. 
The patient may now be nursed in the semirecumbent position with three 
pillows to supp)ort her head and shoulders, a knee pillow under her knees, 
and an air ring beneath her buttocks. 

The bladder is stripped of its normal attachments during this large 
extensive operation and, as it will be paralysed for some days, it is import- 
ant that it should be emptied by catheterization as soon as i o ounces of urine 
have accumulated and it should thereafter never be allowed to become 
overfull. It is routine practice to catheterize these patients every 6 hours 
for as long as necessary. When the bladder begins to regain its tone the 
patient will pass urine voluntarily, but for a considerable time she will 
never empty the bladder completely, and therefore, immediately after 
she has passed urine, the patient should be catheterized — and by immedi- 
ately is meant within five minutes, in order to remove the residual urine. 
At first the residual urine may amount to 5 or 6 ounces, but as the tone 



5^6 GYNAEGOLOOIdAL MUR?SlNO 

of the bladder improves this will decrease in quantity, and only when the 
quantity has become quite minute is it safe to omit catheterization. All 
this time the nurse continues to observe her patient frequently and any 
indication of pain associated with micturition would necessitate the need 
for catheterizing her. Cystitis is a complication which may very readily 
arise owing to the irritability sustained by the bladder during and after 
the o|>eration and for this reason some gynaecologists like their patients 
to have a urinary antiseptic, such as hexamine, and a mild diuretic, such 
as potassium citrate. In addition they should have plenty of bland fluids 
as soon as they are able to take them. 

Dressing, In addition to the wound in the abdominal wall these patients 
are returned to the ward with a packing in the vagina. The gynaecologist 
or his assistant usually removes this after 24-48 hours. The patient con- 
tinues to wear a vaginal pad and the nurse must very particularly note 
the amount of bleeding. As before mentioned, in performing the toilet 
of the vulva whenever the patient is catheterized it is very important to 
dry the interior of the vagina, as with patients lying on their backs this 
forms a cul-de-sac where moisture can collect. 

The diet should be as liberal as possible and, as soon as the patient is 
able to take fluids, nourishment should be freely given and the diet in- 
creased as the patient is willing to take it. The bowels arc kept active by 
the administration of liquid paraffin and phenolphthalein two or three 
times a day, and if this is not efficacious a slightly more drastic aperient 
such as a small dose of cascara is given on the fourth or fifth day. 

Clips and stitches are removed on the fifth and eighth days respec- 
tively, and the patient is usually allowed to get up after 3 weeks and is 
sent home a week later. The complications which may arise are cystitis, 
bleeding and sepsis. 


THE EXAMINATION OF A PATIENT AND SPECIAL 
TREATMENTS 

Preparation oj the patient for gynaecological examination. This examination is 
divided into the following parts: 

( 1 ) Abdominal^ in which the patient lies on her back with knees drawn up. 

(2) Vaginal y in which inspection of the vulva and vagina is made, fol- 
lowed by manual examination and if necessary examination using a 
speculum. 

(3) In bimanual examination two hands are employed, one with which to 
palpate the abdomen while the other hand is in the vagina or rectum, 
and in this way the position of the pelvic organs may be manipulated 
between the two hands. 

(4) Recto-vaginal examination is made in order to ascertain the condition 
of the tissue between the vagina and rectum. One examining finger is in 
the vagina and the other in the rectum. 

The articles which should be provided for a gynaecological examination 
are shown in fig. 172, p. 521. 

These articles include towels to protect the bedclothing and forceps and 
swabs for cleansing the vulva. Rubber gloves, a lubricant, a bowl of anti- 
septic lotion and some swabs should be provided. Instruments which may 
be required are a vaginal speculum, long forceps for holding swabs with 
which to cleanse the vagina, and a long probe. 



EXAMINATION OF A PATIENT 5 1 7 

In preparing a patient for this examination it is important that the 
bladder and rectum and also the lower part of the colon should be empty. 
The vagina should not be douched, as this would remove any discharge 
present which the gynaecologist might want to investigate. The external 
parts of the vulva and perineum should be very clean. The position in 
which the patient is placed may be either the dorsal recumbent^ the left lateral 
or Simses semiprone position (see fig. 30, p. 154). A hassock should be pro- 
vided at the bedside or the side of the couch in case the examining 
gynaecologist wishes to kneel. 

Shaving a gynaecological patient. The ordinary articles required 
for shaving arc prepared. The vulva and perineum cannot be properly 
shaved unless a good light is provided; the nurse must be able to see what 
she is doing and shaving should not be attempted under the bedclothes. 

The order of procedure is rather important. When a ‘ through ’ shave is 
carried out, the hairs on the abdominal wall should first be removed, then 
those on the mons veneris and vulva; and after this the patient should be 
turned on her side and the hairs on the perineum should be removed, and 
those over the buttocks and lower part of the back as well. 

It is quite usual for the patient to have a bath immediately after shaving 
to remove all the short cut hair, but if it is not advisable for the patient 
to go to the bathroom the parts should be thoroughly well washed to 
remove all the bits of hair, and then dried and powdered, unless a skin 
preparation is to follow the shaving. 

GYNAECOLOGICAL TREATMENTS 

The toilet of the vulva. A nurse will be frequently required to perform 
the toilet of the vulva, particularly after operations on the vagina and 
perineum, and whenever catheterization is employed, and with many bed 
cases who are unable to wash themselves. 

The bed should be protected by a drawsheet and mackintosh, in some 
cases a special mackintosh and towel being provided. The patient should 
lie on her back in a semirecumbent position, the bedclothes being care- 
fully folded, so that the upper part of her body is protected from chilling 
and her legs covered to above the knees. The nurse then washes the vulva 
and all the surrounding parts, with soap and water, also the inner sides of 
the thighs, paying special attention to the groins. Sterile swabs should be 
used for the internal labia and the inner aispect of the vagina; in some 
cases these parts arc irrigated, not as described in the vaginal douche, 
but by allowing the saline or lotion used to flow gently over the different 
parts. Great care must be taken to dry the inner aspect of the labia by 
gently swabbing and not by rubbing as the latter might remove the sur- 
face epithelium and produces soreness. It is very important in the case of 
patients who are nursed cn the back that the vaginal orifice be kept quite 
dry, as urine tends to collect in the posterior part of it and decomposition 
quickly gives rise to sepsis. 

After the front parts have been attended to the patient should be turned 
on her side and the surface of the perineum and the area all round the 
rectum carefully washed, dried and powdered. If there are stitches in the 
perineum the case will be dealt with as described in the post-operative 
nursing of perineorrhaphy on p. 51 1. 



5i8 gynaecological nursing 

Insertion of tampons* Tampons may be balls of absorbent wool tied 
up in gauze (see fig, 173, p. 52s) and saturated with some antiseptic, 
astringent or other substance; or the substance may be prepared ready in 
gelatine pessaries. 

To insert a tampon the patient should lie on her back or in the left 
lateral or in Sims's semiprone position; the bed should be protected and 
the patient adequately covered to prevent exposure and chilling. The 
vulva and the internal aspect of the vagina arc swabbed and rendered 
quite free of discharge; a vaginal speculum is lubricated and inserted; or, 
alternatively, it may be sufficient for the nurse to retract the anterior 
part of the vagina with the first two fingers of her left hand. She then 
swabs and dries the interior of the vagina as far as she can reach, using 
sterile swabs on sponge-holding forceps. The tampon is taken between the 
blades of a pair of long forceps and inserted into the posterior fornix of the 
vagina as far as possible. If there is a tape or string attached to the tampon 
this should be left just inside the vaginal orifice, at the margin of the vulva, 
so that it can be easily reached when the tampon is to be moved later. 

Packing the vagina. In many instances this treatment is performed by 
the gynaecologist or house surgeon. The occasions when a nurse will be 
asked to pack a vagina will be ( i ) as an emergency measure in the treat- 
ment of severe uterine haemorrhage when the help of a doctor cannot 
immediately be obtained, and also (2) when the gynaecologist requires 
the vagina packed with gauze soaked in some antiseptic previous to an 
operation on the vagina or uterus. In the latter case the vagina should only 
be lightly packed, and it is a very simple procedure and can be rendered 
quite painless. Having the roll of gauze in a bowl the nurse takes hold of 
the end of it with a pair of forceps and, either using the spatula or retract- 
ing the anterior vaginal wall with her fingers, gently plugs the cavity. 

In packing the vagina in the treatment of serious uterine haemorrhage 
much fiiTner pressure is necessary. There may not be time to permit the 
patient to empty her bladder but if possible she should do so as she will be 
unable to pass urine afterwards. When blood is pouring from a patient’s 
uterus there is usually no time to give an anaesthetic, but a ^ grain of 
morphia is sometimes given. As a result of the shock the patient is ren- 
dered comparatively immune to discomfort, and it is only when the condi- 
tion is as serious as here indicated that a nurse would be called upon to 
insert the pack. 

In this case the gauze, soaked in some antiseptic, should be folded in 
three and packed firmly into the posterior fornix, continuing to pack 
firmly until the whole cavity is tightly packed and if necessary applying 
manual pressure on the pack until help can be obtained and the patient 
given an anaesthetic and the packing more tightly applied. 

Pessaries. These arc solid substances, frequently medicated, which are 
similar in shape to suppositories and may be described as vaginal supposi^- 
lories. They arc larger than the suppositories used for insertion into the 
rectum, and they are inserted in a very similar way to that described for 
the insertion of tampons (see fig. 173, p. 522, letter A). Pessaries of rubber 
or composition are used in the treatment of uterine displacement in some 
instances. 

Hodge^s pessary (sec letter B) is used to correct retroversion of the uterus 
after childbirth. The obstetrician inserts the pessary which helps to keep 



GYNAECOLOGICAL TREATMENTS 519 

the uterus forward. This simple means may be sufficient to correct the 
condition permanently; if it docs not do so, three months later an opera- 
tion will be undertaken for correction of the condition. 

A ring pessary or watch spring consists of springs enclosed in rubber. It is 
used in the correction of slight prolapse of the uterus. In some cases a nurse 
is asked to insert this. She should have the woman lying in the left lateral 
position. The pcssatry is sterilized either by boiling or by standing in 
perchloride of mercury 1/2,000 solution for an hour. It is taken in the 
right hand and compressed, passed into the vagina and then allowed to 
expand. The cervix can be felt through the ring when the pessary is in the 
correct position — around the cervix, impinging on the walls of the vagina, 
and so correcting the tendency to prolapse. It is necessary to ascertain 
that the pessary is not displaced by coughing or straining before the woman 
is allowed to get off the couch. The patient should have a vaginal douche 
every day whilst wearing a pessary and must be seen by the gynaecolo^t 
or obstetrician every three months. If this treatment is not effective 
witliin a reasonable time, operative treatment will be undertaken. No 
woman should be condemned to wear a pessary for an indefinite time. 
(Letter D in fig. 173, p. 522 shows a watch spring pessary introducer; this 
is employed when the fingers of the operator are not strong enough to 
compress the pessary efficiently.) 

Napier^s cup and stem pessary (see letter E) is employed for the relief of 
prolapse of the uterus in very elderly women, in whom, for one reason or 
another, operative treatment may be contra-indicated. The pessary is 
prepared by soaking in mercury, it is inserted with the woman lying on a 
couch or in bed — it is usually inserted daily before she gets up in the 
morning. The cervix is supported on the cup; the pessary is maintained in 
position by tying the tapes — two behind and two in front — to a belt 
worn round the waist. It is removed at night, wsished to render it free 
from mucus and then placed in a solution of mercury when it will be ready 
for use next morning. 

Catheterization and vaginal douching are described on pp. 138 and 
143 * 



Chapter 34 

Inflammatory Conditions, Diseases and Disorders 
of the Female Generative Organs 

Ascending inflammation of the genital tract: vulvitis^ vaginitis ^ cervicitis^ endome* 
tritis and salpingitis — Ruptured ectopic gestation — Disorders of the uterus: 
amenorrhoea, dysmenorrhoea^ menorrhagia and metrorrhagia-^Displacement of the 
uterus — Diseases of the uterus {including cancer) and diseases of the ovaries 

I n addition to the conditions dealt with in the previous pages on 
gynaecological nursing, the following short notes on some conditions 
and diseases of the reproductive organs with which a nurse should be 
familiar may be found useful. 

Ascending inflammation of the genital tract is most commonly 
due to some pus-producing organism such as streptococci, pneumococci, 
bacillus coli, staphylococci and more rarely to the presence of gonococci. 
Any part of the tract may be infected. 

The vulva (vulvitis). This is usually a simple inflammation due to an 
abrasion which has been infected by staphylococci. In some instances 
streptococci may be the causative organism and in such cases the condition 
is more severe, the vulva becoming red, dry and swollen, and possibly 
ulcerated. In severe cases infection of Bartholin's gland occurs and a Bar- 
tholinian abscess may be formed. This is manifested by a painful swelling 
distending the labia majora. 

Vulvitis is treated by cleanliness, by frequent hot baths and by irrigation 
of the vulva with antiseptic solutions. A Bartholin's abscess usually requires 
to be incised, drained and packed, allowing it to heal from the bottom, 
and the parts should be kept as clean as possible during the process of 
healing. 

The vagina (vaginitis). This condition is due to the same cause as 
vulvitis and may be combined with it in vulvovaginitis. The vagina resists 
sepsis fairly well, but infection of the vagina usually spreads to the vault 
where the cervix of the uterus lies, resulting in cervicitis; the inflammatory 
condition of the cervix gives rise to a profuse discharge which, passing 
over the surface of the vagina, is a contributorjr factor in causing reinfec- 
tion thereof. In many cases vaginitis tends to become chronic, simple 
vaginitis does not usually spread very much — it is the more acute varieties 
which spread up the tract and give rise to infection of the fallopian tubes 
{salpingitis) , 

The uterus. Cervicitis is infection of the neck, and endometritis of the 
body, of the uterus. The term 'endocervicitis' is also employed to indicate 
inflammation of the inner part of the cervix. Cervicitis is usually a mild 
infection, and it may follow childbearing or occur as a result of vaginitis. 
It is characterized by a vaginal discharge which is most marked during 
the days immediately preceding and following menstruation, and is 
accompanied by backache and some degree of general malaise. The in- 
flammatory condition of the cervix may be a cause of cervical erosion. 

520 



52 1 


■ 3»:#.!:'n 7r:vww : 



1 ’ K ; . I 7 '-2 . — see pa^e 516. 

IJri’KR SnKi_i\ (ilovrs, lubricant, swabs and instru- 
mc'nts. Kradint; ironi la'ft to Hi^ht: Ousco's, Sims' 
an I 1 c‘ru:usson's s]>rrula, two pairs of swab-holding 
forceps. At the lop of tlu' tray: l^layfair's probe and 
uterine sound. 

l^owKK S11E.LF. Towels to protect the V:>ed. Swabs, 
forceps and lotion for cleansing the vulva. Receptacles 
for soiled sw abs 'and used instruments. 




523 



I'k;. 17',. — paf^cs f,4() 7,41. Artic les rrciuirt'd for the loc al trc^atnicnt 
of gotiori hex'a in lc‘inalc“ ])ali<‘iUs. An irrigation can with tubing and 
noz/.lc* is supplied tor urethral irrigation. Reading iroin le ft to right: 
( aisc c)*s vaginal sjx-cuhun, t'orcc-ps tor liolding swabs and lor the insc'rtion 
ot gauze packing and an a|)plieator for ointme nt. 



hu;. 17b. Fergusson's vaginal speculum may alterna- 
tivc-ly be emj^loyed particularly for the purpose of 
applic atic^ns to the cervix. 



524 




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THE FEMALE GENERATIVE ORGANS 5129 

In cervical erosion the surfaces of the cervix become red and raw, and 
they may be ulcerated or lacerated. Erosion means eating away, and it 
may be the result of chronic infection in which an irritating discharge is 
destroying the surface tissue, or it may be due to gonorrhoea, or follow 
lacerations of the cervix as the result of childbearing. In some cases the 
operation of amputation of the cervix is employed to cure the condition 
when local applications of antiseptics and astringent substances have 
failed to produce relief. 

Endometritis is inflammation of the lining of the uterus which becomes 
very congested; this condition is associated with excessive menstruation, 
and a persistent vaginal discharge which is thin and watery in character 
results from it. Tlie operation of uterine curettage may be necessary to 
relieve this condition. 

Metritisy which results in thickening of the walls of the uterus, may be 
due to spread of the inflammation from the endometrium, or it may follow 
puerperal sepsis. It is accompanied by excessive menstruation which 
occurs in women who have borne several children and who are in a state 
of chronic ill health. It is usually treated by hysterectomy and in some 
cases by applications of X rays and radium. 

The fallopian tubes (salpingitis). Inflammation of the fallopian 
tubes may be due to ascending infection from the vagina, or to descending 
infection from the peritoneal cavity such as occurs in appendicitis, and 
the condition may be simple, in which it is catarrhal, or suppurative, 
when pus-producing organisms are present. The former may be due to 
staphylococcal infection and in this case the distension of the tube by 
serous fluid is described as hydrosalpinx. When pus-producing organisms 
are present the condition is designated as pyosalpinx\ infection frequently 
spreads to the ovaries, giving rise to a pelvic abscess and pelvic peritonitis. 

The condition is usually bilateral, and it may be either acute or chronic. 
In the chronic variety there is a serous vaginal discharge which is a 
characteristic greenish offensive fluid, most profuse during the days pre- 
ceding menstiTiation. The patient has a slight rise of temperature — 99^ 
to 100^ F., accompanied by a varying degree of malaise, with pain in the 
back and sides. This chronic form may be treated by medical measures. The 
patient is kept in bed to rest, a light nourishing diet is administered, 
the bowels are kept regularly active, applications of heat are made to the 
lateral abdominal wall, hot vaginal douches and antiseptic tampons such 
as glycerine and ichthyol are employed. 

Acute salpingitis is suppurative in character and the symptoms in a patient 
admitted with this condition are those of general peritonitis. The onset is 
usually sudden, accompanied by a rigor and a rise of temperature. The 
patient has acute abdominal pain, with tenderness and distension, the 
pulse is rapid and there is nausea and vomiting. The patient looks very ill. 

The treatment of this condition is laparotomy, with removal of the in- 
fected tube [salpingectomy) y and drainage of the peritoneum; if the ovaries 
are infected the operation of salpingo^oophorectomy is performed. 

It is important to remember that a mild degree of salpingitis may 
become chronic. The chronic type may be tuberculous in origin. 

Tubal gestation is growth of the fertilized ovum in the fallopian tube. 
It may also be called ectopic gestationy and extra-uterine gestation. Abdominal 
gestation and even ovarian gestation may also occur. 



530 rilU FEMALE GENEEATtVE 0EGAK8 

When tubal gestation occurs, in a very short time the ovum burrows its 
way into the wall of the thin tube, and usually causes it to rupture. In a 
few cases of abdominal gestation the pregnancy may go on to term, but 
it is dangerous, owing to excessive bleeding which follows the separation 
of the placenta. In other cases the foetus dies and becomes calcified. It is 
then described as a lithopaedion. 

Ruptured tubal gestation. This is an emergency with which a nurse 
will have to help to deal. The usual history obtained is that the patient 
has usually missed one or two periods. The present attack has come on 
suddenly, and is characteristic of an acute abdominal catastrophe. The 
patient collapses and is extremely pale, being blanched in appearance. 
There is acute abdominal pain, the abdomen is tender and there is usually 
nausea and vomiting. In other cases the symptoms may be very slight 
and may pass unnoticed. 

The treatment is to open the abdominal cavity and remove the blood 
which has poured into it. Pending the operation palliative treatment for 
shock in the form of blood transfusion and saline infusion is carried out. A 
serious case of ruptured ectopic gestation presents the most dramatic 
degree of shock that a nurse will ever see — and as this is due to the haemor- 
rhage that has occurred, combined with imitation of the peritoneum 
resulting from the presence of blood in it, in her post-operative nursing care 
she has therefore primarily the^e conditions to take into account. 

As soon as possible the patient will be placed in Fowler’s position in 
order to assist drainage from the vagina. The vaginal discharge will be 
collected on sterile pads and will be very carefully inspected. A careful 
record of the tcm}>eraturc and pulse must be kept, fluids should be ad- 
ministered freely, the bowels must be regularly active, and the patient 
requires to be as well nourished as possible as, owing to the lowering of her 
vitality, the complication to be feared in the later days of the illness is 
abdominal sepsis. 


DISORDERS OF THE UTERUS 

Disorders of menstraatlon are frequently met with in abnormal con- 
ditions of the uterus. Amenorrhoea, or absence of menstruation, is normal 
before puberty and after the menopausc;itsabsenccduringthcmenstruating 
period is most usually due to pregnancy, though absence may also occur 
as a result of general ill health, particularly associated with constitutional 
disease of the heart, lungs and kidneys, and diseases of the ovaries; and it 
also occurs as a result of emotional disturbance, disease of the endocrine 
organs, and is an inevitable result of hysterectomy and bilateral oophorec- 
tomy. 

When the condition is brought about by some disease or ill health the 
cause has to be dealt with, otherwise no treatment need be suggested. The 
condition will right itself, and the fortunate woman might, in the mean- 
time, consider herself a favoured individual. 

A condition which is described as apparent amenorrhoea is due to an 
abnormality of the hymen, when the latter is not perforated {imperforate 
hymen). In these cases menstruation occurs, but the discharge cannot 
escape and remains pent up in the vaginal cavity until the hymen is 
divided. 



D1»OROSR8 OF THE UTERUfi 53 1 

Dysmenorrhoea is the term used to describe any difficult or painful 
menstruation. A ntimber of types are described. Spasmodic dysmenorrhota is 
the type which occurs in young women 2 to 3 years after the onset of 
menstruation; the pain, which coincides with die onset of the period, is 
in the lower part of the abdomen and in the middle line, and lasts from 
5 to 6 hours and in some cases for a whole day and may be very disabling. 
As the subject grows older it may improve — if not, it may have to be 
treated by dilatation of the os uteri. This type of dysmenorrhoea is usually 
cured by a first pregnancy. 

Congestive dysmenorrhoea, which occurs in older women, and is more 
common in those who have had children. The pain in these cases precedes 
menstruation for a day or two and is accompanied by severe backache. 

Obstructive dysmenorrhoea is the type in which the pain is colicky. It is also 
described as ‘clot’ dysmenorrhoea, because it is thought to be due to 
the forcible contraction of the uterus on a clot in an endeavour to remove 
it — after a clot is passed the pain seems to be relieved. 

Menorrhagia is excessive loss at the menstrual period, and metrorr- 
hagia is bleeding between the periods. 

It is important that a nurse should be able to help a woman to estimate 
the amount of menstruation, and this may be arrived at by considering 
the number of diapers she uses — over eighteen would be definitely exces- 
sive. The duration of the menstrual period and its frequency should also be 
noted, as in some cases it may occur at fortnightly intervals instead of 
monthly, also the number of clots passed, as clotting is definitely abnormal. 
The degree of anaemia from which the woman appears to be suffering, 
indicated by pallor of skin and mucous surfaces, would also suggest an 
excessive loss. 

Displacements of the uterus. The commonest displacements of the 
uterus are retroversion and prolapse. In retroversion the uterus is lying 
backwards instead of forward. It is due to weakness of the ligaments 
which normally hold the uterus in the correct position of anteversion. 
This weakness is most commonly brought about by childbearing, but any 
laxity of muscle tone indicates laxity of ligaments also, and in the case of 
growing girls any sudden strain may jerk the uterus out of its normal 
position and cause retroversion. 

The condition is accompanied by backache, excessive menstruation 
and Icucorrhoea. The treatment adopted is surgical, either ventro-fixation 
or shortening of round ligaments being performed. 

Uterine prolapse. In this condition the vaginal walls become stretched; it 
may be brought about by lack of support owing to injury to the perineum, 
the vaginal wall begins to evert, bringing the uterus down with it. The 
condition is ffequentiy accompanied by some degree of cystocele or rectocele. 

The condition of cystocele is due to protrusion of the bladder into the 
anterior vaginal wall owing to the stretching of that wall. It frequently 
accompanies tearing of the perineal body. 

The condition is rectified by anterior colporrhaphy. The preparation 
and post-operative nursing is similar to that described on p. 51 1, except 
that the patient is nursed as fiat as possible when repair of the anterior 
vaginal is carried out. She will usually have difficulty with micturi- 
tion, and catheterization may be necessary. Copious fluids are adminis- 
tered and urinary antiseptics employed. It is important to measure the 



532 THE FEMALE GENERATIVE ORGANS 

intake of fluid, and to compare it with the output of urine as the nurse 
must be very careful not to allow residual urine to be retained. As a rule 
a vaginal packing is inserted and removed 24 hours after the operation. 
In performing the toilet of the vulva the interior of the vagina must be 
carefully dried. As catgut stitches are employed these should be expected 
to slough away after about a week and the increase in discharge which 
accompanies this process would necessitate frequent swabbing of the 
vagina. 

Rectocele. In this case there is prolapse of the posterior vaginal wall, 
with the rectum protruding into it. It is due to the same cause as described 
in the case of cystocele. In repair of this condition, posterior colporrhaphy 
is frequently combined with perineorrhaphy, as the condition is commonly 
associated with tearing of the pelvic floor and perineal body. 


DISEASES OF THE UTERUS AND OVARIES 

Fibroid tumours of the uterus. The non-pregnant uterus is a canal 
with a strong muscular wall, lined with endometrium and covered with 
peritoneum. A fibroid tumour is a myoma^ or a tumour of the muscular 
wall of the uterus. When it occurs in the wall it is described as intramural^ 
and when near the outer aspect projecting under the peritoneum, as 
subperitonealy and when it is nearest the inner lining of the uterus projecting 
under the mucous surface, it is described as a submucous tumour. A fourth 
variety is polypoid in character, and in this case the whole tumour projects 
into the uterine cavity. This type usually bleeds very easily. 

The symptoms of the presence of a fibroid tumour are due to enlargement 
of the uterus. There is excessive loss at the periods, and, when the tumour 
is polypoid in character, bleeding occurs between the periods also. The 
presence of fibroid tumours results in delay of the menopause, which 
instead of beginning at the age of 48 may not occur till the woman is well 
over 50. Large tumours give rise to swelling and cause pressure on the 
adjacent organs producing difficulty of micturition, predisposing to 
haerriorrhoids and varicose veins, causing constipation and in some cases 
giving rise to sciatica. 

Treatment, When the tumours arc small, and the woman is young, 
myomectomy is performed. If the tumours are large and the woman is over 
forty, hysterectomy may be performed or radium treatment may be em- 
ployed. 

Cancer of the uterus is usually carcinomatous in type. It may affect 
the body of the organ or the cervix. It is comparatively uncommon but 
very serious in its effects, particularly carcinoma of the cervix. 

Carcinoma of the body of the uterus rarely occurs until after the 
menopause, at the age of from 50 to 60 years; it begins in the lining, 
endometrium, and ulcerates through on to the outer wall of the uterus 
where it extends to the peritoneum. This is spread by infiltration of 
the tissues as described by Mr. Sampson Handley, who also described the 
spread of cancer by lymphatic permeation. In cancer of the uterus the 
disease spreads by the lymphatics which pass out from the uterus in 
the broad ligaments to the sides of the pelvis; these then join up with the 
lymphatics passing up from the lower limbs and track along the course 
of the iliac vessels to the front of the aorta where numerous lymphatic 



DISEASES OF UTERUS AND OVARIES 533 

glands lie; these then become infected and enlarged. Later, the disease 
tracks along the lymphatics to the glands in the thorax which also become 
infected. 

The chief symptom of carcinoma of the body of the uterus is post-menopausal 
bleeding; the usual history is that a woman had her menopause say at 
49 or 50; then, 2, 3 or 4 years later she noticed slight bleeding; this was 
only a spot or two at first, but it increased and in a short time became 
continuous. Bleeding continued for several months and then she noticed 
that the character changed and became a discharge, which after a little 
further period of time became offensive in odour. 

If these symptoms are neglected she will then have pain, difficulty of 
micturition and frequency, and later will notice that her abdomen 
becomes enlarged as ascites sets in, owing to infection of the peritoneum. 

Carcinoma of the cervix has a wider age distribution, but is very rare 
indeed; most cases seen occur between the ages of 30 and 50, though some 
may occur earlier and others later than this. 

The disease starts at the cervix, and spreads by infiltration of the tissue 
in this region and, as the cervix of the uterus is closely related to other 
organs, the disease rapidly spreads; from the front it reaches the bladder, 
from the back it spreads to the pouch of Douglas and the rectum, spread- 
ing laterally it infiltrates the cardinal ligaments and involves the ureters 
and, spreading downwards, infiltrates the vagina. 

It also spreads by lymphatic permeation in much the same way as 
described in cancer of the body of the uterus. 

The chief symptom is bleeding. A woman of from 40 to 50 years of age 
should have regular menstrual periods; in carcinoma of the cervix she 
will also bleed between her periods and this will go on, till after a compara- 
tively short time she is never free from bleeding. Bleeding between the 
periods begins as an irregular spotting, after a time there is a continuous 
show which changes in character, and after quite a short time becomes an 
offensive discharge. 

Pain occurs considerably later when the bladder and rectum are 
involved; it is a dull aching pain, complained of about the lower part of 
the abdomen and vagina. 

In a serious untreated case the picture presented is of a debilitated 
woman, weakened by continued bleeding, poisoned by an offensive dis- 
charge, irritated by discharge escaping by the bladder and rectum, both 
of which arc by now involved in the disease. The ureters become ob- 
structed and suppression of urine occurs. 

Both in cancer of the body of the uterus and the cervix secondary 
deposits may arise in distant organs, carried there by lymphatic permea- 
tion, and reaching the organs in the blood stream. Those most conunonly 
affected arc the lungs, brain and bones. 

Treatment. Carcinoma of the body is treated by pan-hysterectomy, that 
is removal of the uterus, with the ovaries and fallopian tubes. Many 
gynaecologists consider that cancer of the cervix needs the performance of 
Wertheim's operation for successful treatment. In this operation the 
uterus, with the vagina, ovaries and fallopian tubes and all the ligaments 
and lymphatic tissue in the pelvis are removed. 

Treatrnent by radium and X rays is undertaken in some cases. It depends 



534 FEMALE aEKERATIVE ORGANS 

on the condition of the growth and the choice the surgeon who is con- 
sulted makes, as to the typ>e of treatment adopted. 

Other forms of cancer may also affect the uterus. 

Sarcoma begins in connective tissue, such as muscle, and may occur as 
the result of cancerous degeneration of a uterine fibroid. As a rule pan- 
hysterectomy is performed in these cases. 

Chorio -carcinoma is an interesting but extremely rare form of cancer 
which may arise in the uterus. It is the result of abnormal behaviour of the 
trophoblastic cells which form the chorionic villi which become engrafted 
on to the wall of the uterus to form the placenta. Normally, when the 
organ through which the interchange of nourishment is to pass from the 
mother’s blood to the foetus is established, the growth of the placenta 
ceases and pregnancy proceeds. If it does not cease cancerous changes 
occur, the cancer cells rapidly invade the lymphatics and, passing on to 
the blood stream, result in secondary carcinomatous growths in various 
organs. Operative treatment is necessary as soon as this rare condition is 
diagnosed. 

DISEASES OF THE OVARIES 

Ovarian abscess has already been mentioned in connexion with 
pyosalpinx. 

Ovarian tumours may be cystic or solid, the commonest being an 
ovarian cyst, which may reach a very large size, and be either unilateral or 
bilateral, and unilocular or multilocular. A simple cyst contains pure fluid; 
a glandular cyst is filled with mucoid glairy fluid; a papillomatous cyst con- 
tains watery growths; a blood cyst is due to effusion of blood into the ovary; 
and a dermoid cyst contains particles of skin, hair, teeth, &c. 

The symptoms of ovarian (yst depend upon its size, and are due to dis- 
comfort from pressure, giving rise to indigestion, constipation and diffi- 
culty of micturition. Dysmenorrhoea and excessive menstruation may 
accompany the condition. The usual ovarian cyst consists of a body and a 
pedicle, and the dangers of the condition are rupture of the cyst, torsion of the 
pedicle giving rise to gangrene and infection of the cyst. The treatment is 
removal of the cyst. 



Chapter 35 

A Short Outline of Venereal Diseases and their 
Management 

A short account of syphilis and its treatment — The mode of infection in gonorrhoea^ 
acute and chronic stages^ treatment — A note on soft sore 

I t is desirable that every nurse, however junior she may be, should have 
some idea of venereal disease and the types most commonly met with. 
It is sufficient to say in description that a venereal disease is one 
acquired in a venereal manner. There are three diseases described, (i) 
Syphilis, due to the spirochaeta pallida, which was described by Schaudinn 
and Hoffman in 1905. Since that date the term ‘Treponema pallidum' has 
been adopted by the International Committee on nomenclature, and this 
is now the only correct name for the organism of syphilis. 

(2) Gonorrhoea, due to the presence of neisseria gonorrhoeae (the 
diplococcus of Neisser) discovered in 1872. 

(3) Ducrey’s bacillus, discovered in 1884. 

Prevention of venereal disease. The only sane approach to the pre- 
vention of venereal disease is by education, and not by compulsion. 
Education may take longer but it will be more effective. Venereal disease 
is contracted principally by sexual promiscuity and what is needed to deal 
with this evil is a higher standard of the ideal of sex. At present the moral 
stigma attaches to those unfortunate victims of disease and not to those 
who have escaped! When public opinion hates the evil without judging the 
victim of disease then a standard will be reached and progress in the pre- 
vention of venereal disease may be expected. 

As nurses we treat the individual patient without asking how or why. 
Early and adequate treatment is essential if success is to be attained. 
Treatment may be long, and the patient will require all the help and 
encouragement we can give in order to persevere until a cure is estab- 
lished. The following notes contain some idea of how far reaching in its 
disabling effects syphilis, for example, can be. 

Nurses are a large section of the community and one which can contri- 
bute a great deal towards teaching the public what is the right attitude 
to adopt towards the prevention of venereal disease. 

SYPHILIS 

Syphilis is a disease which runs a definite course passing through several 
phases. The length of the incubation period is from 3 to 4 weeks, with 
extreme limits of from 10 days to 3 months. Infection is conveyed by sexual 
intercourse, and in addition in a few cases it may be transmitted by 
kissing. In these cases the mouth and lips are the site of infection. It may 
also be contracted by doctors, nurses and midwives handling infected 
material. 

Syphilis may be prenatal (congenital), or acquired. The first clinical sign 
of acquired syphilis is, usually, the occurrence of a primary sore or chancre at 

535 



536 VENEREAL DISEASES 

the site of inoculation, in men on the penis, and in women on some part 
of the genital area. The lesion is described as extragenital when it occurs 
on some other part, as for example, in the case of a doctor or midwife, 
when it may occur on an infected finger. 

The treponema pallidum entfcrs the body at the site of inoculation. It 
causes a local reaction which results in the appearance of the chancre 
and possibly also of some adenitis of the neighbouring lymphatic glands. 
But the organism or parasite of syphilis not only invades the tissues, it also 
invades the blood stream so that a general as well as a local infection is 
established. 

Classification. The phases or stages of syphilis were formerly des- 
cribed under the Ricordian classification as: 

Primary. The appearance of the chancre. 

Secondary. Appearance of rash and constitutional symptoms. 

Latent. A period during wliich no symptoms were present. 

Tertiary. The stage when symptoms of the cardio- vascular system, 
viscera and nervous system appeared. 

But this classification has been superseded by the more useful one 
elaborated by the late Dr. E. T. Burke in his work on Venereal Diseases 
in which syphilis is divided into two stages, acute and chronic, each con- 
taining a number of degrees. 

First degree, primary stage, Wassermann negative 
Second „ „ „ „ positive 

Third degree, secondary stage, Early 
Fourth „ „ „ Late 

Fifth degree, Endosyphilis (see p. 537) 

Sixth „ Tertiary with viscer^ changes 

Seventh ,, Neurosyphilis 

Eighth „ Prenatal (Congenital) 

Dr. Burke also described the significance of considering syphilis in the 
age group in which it occurs: 

(1) Before the age of 20 years. In these cases the gravest and most 
irreparable damage occurs in the tissues because the body is still develop- 
ing and the tissues are very vulnerable to attack by the treponema 
pallidum. 

(2) From 20 to 50 years. This is the age when man is at his prime and 
the tissues are more resistant, so that although the effects of syphilis are 
severe they are not as devastating as when the disease is contracted before 
the age of 20 or after the age of 50. 

(3) Over 50 years. Man is now past his prime, his body is less resistant 
to disease and if syphilis is contracted great damage is likely to ensue. 

The primary phase (first and second degrees) is characterized by the 
initial reaction and appearance of the chancre 3 to 4 weeks after infection. 
Towards the end of this phase the Wassermann reaction is positive. 

The secondary phase (third and fourth degrees) occurs some 3 to 4 weeks 
later or about 2 months after the initial infection, it is characterized by a 
rash and constitutional symptoms. The rash appears on the trunk and 
arms, face, palms and soles, and over the anal, perineal and genital 
regions. It may be pinkish, dull red, macular, papiilar or pustular. When 
on the anal and genital regions it may take the appearance of patches, 


Acute Syphilis | 
. ( 

Chronic Syphilis 



SYPHILIS 537 

or wartJike or cauliflower growths. All nurses should be warned that small 
erosions, sores, or wart-like growths over the genitalia should not be 
touched, the matter should be reported to the head nurse or ward sister 
without mentioning the fact to the patient. These lesions are teeming 
with the parasites of syphilis and are a source of infection by contact. 

The constitutianal symptoms may be slight, mild or severe. In the majority 
of cases they may be described as mild, and include sore throat, hoarseness, 
headache, malaise, general pains and some rise of temperature. The throat 
may be red or ulcerated — a snail-track ulcer is characteristic of syphilis. 

Malignant syphilis. This type is rare. The term malignant is used to 
describe cases in which there is definite ulceration of the skin. The patient 
becomes very toxic, is anaemic, emaciated and extremely ill, and usually 
dies after several weeks’ illness. 

Chronic syphilis or the third phase of the disease includes what was 
formerly described as the latent’ period followed by the symptoms of the 
tertiary phase. But the valuable work of Professor Warthin of Michigan 
has shown that syphilis is a progressive disease^ and is never latent. The term 
endosyphilis is used to describe the period during which clinical signs of 
disease are not evident. Endosyphilis implies that active pathological 
changes are taking place within the tissues, changes which will result later 
in serious disablement. Lesions characteristic of chronic syphilis are 
numerous and may be classified as follows: 

Cutaneous lesions such as syphilitic ulcers and gummatous tumours of the 
skin. 

Lesions of mucous surfaces such as leukoplakia of tlie tongue and fauces, 
ulcers, gummatous tumours and erosion of the palate with perforation. 

Lesions of bone and muscle include gummatous tumours, periostitis, 
osteitis, osteomyelitis and dactylitis. Joints may be the site of synovitis 
and arthritis and muscles of gummata. 

Cardio-vascular syphilis is one of the most serious forms because any part 
of the circulatory system may be affected causing great disablement. 
These diseases may be classified as affecting: 

The heart. Endocarditis, pericarditis, and myocarditis may occur. 
Degeneration or tumour may arise in Ae bundle of His causing heart 
block. Arteritis of the coronary vessels will cause angina pectoris. 

The aorta may be affected by aortitis, tumour, dilatation and aneurysm. 

The blood vessels by arteritis and arteriosclerosis giving rise to hyper- 
tension. Raynaud’s disease may be due to syphilis. Gummatous tumours 
may arise in the walls of any of the blood vessels and in the lymphatics. 

The blood, A primary pernicious anaemia may occur during the stage 
of chronic syphilis. 

Neurosyphilis, Syphilitic meningitis may occur. Endarteritis of the 
cerebral vessels may result in thrombosis, aneurysm, or cerebral haemor- 
rhage causing hemiplegia, diplegia or monoplegia. Gummatous tumours 
may arise in the brain or spinal cord. Locomotor ataxia (tabes dorsalis) and 
general paralysis of the insane (G.P.I.) or a combination of these, tabo- 
paresis may occur. 

Visceral syphilis. The nose, larynx, bronchi, lungs and pleura — the 
salivary glands, oesophagus, stomach, intestine and rectum — the pancreas, 
spleen and liver — the kidneys and bladder — any part of the male and 
female genital tract — some of the endocrine glands — the optic nerve, eye 



538 VENEREAL DISEASES 

and eyelids — the pinna, middle and inner car may all be sites of syphilitic 
lesions. 

Prenatal {Congenital) syphilis is subdivided into early and late manifesta- 
tions. The parasite of syphilis causes very destructive changes in the 
developing foetus and the result may be abortion, a macerated foetus or 
stillbirth. When the child is bom ^ive, if premature he will have the 
appearance of a little wizened old man; if bom at term symptoms of 
syphilis will develop within the first 2 weeks of life — the earlier the symp- 
toms appear the more serious is the condition of the infant. 

Early signs of prenatal syphilis include rashes, snuffles, cracks and fissures 
about the mouth, and characteristic lesions of the mucous surfaces. The 
child may cry a great deal and scream when handled. He probably has 
some bone lesion, osteochondritis or epiphysitis, and handling causes pain. 
Many of these infants do not survive for long. 

Signs of late prenatal syphilis. The classical signs include the saddle-shaped 
nose due to ulceration of the nasal bones; Hutchinson^s notched or peg- 
shaped teeth which occur in the second dentition; eye lesions include 
interstitial keratitis and choroiditis. There may be thickening of bone and 
swelling at the joints. Juvenile neurosyphilis takes the form of mental 
deficiency, epilepsy, juvenile tabes dors^is and general paralysis of the 
insane. 

Tests used in syphilis. Microscopic examination of blood serum from 
the chancre, or from one of the infected glands is carried out on a dark 
background slide. The T. pallidum is seen as a delicate white spiral. The 
Wassermann or complemenifixaiion test is performed on blood serum and on 
cerebrospinal fluid. The Kahn modification of the flocculation test is per- 
formed on blood serum. 

Treatment. The method of applying treatment in syphilis varies. 
Some authorities consider that courses of treatment by arsenic and bis- 
muth or mercury should be given at regular intervals; others think that 
treatment should be continuous, and that treatment-free periods are 
dangerous because the parasite may work its destruction unham{>ered 
during a period free from treatment. But both schools of thought are 
united in teaching that treatment must be adequate and effective if the 
disabling diseases which characterize chronic syphilis (see p. 537) are to 
be avoided and that cases should be under observation until danger of 
relapse is over. The drugs used are arsenic, bismuth, mercury and 
iodides. 

Arsenic is used in the form of an organic compound which has a destruc- 
tive action on the parasite of syphilis. The first suitable compound was 
elaborated by Dr. Ehrlich ; being his 6o6th experiment it became known 
as ‘606’ (salvarsan or arsphenamine). A later experiment is ‘914* (neosal- 
varsan or ncoarsphenamine). Many arsenic compounds arc available 
today, the majority being administered by the intravenous route. 

Arsenic is a very poisonous metal^ and it is necessary to prepare the patient 
for an intravenous injection of arsenic as he would be prepared for a 
general anaesthetic — that is, a mild aperient should be given and the 
bowels rendered active, and the urine tested for albumin and sugar. If 
either of these substances is present the matter must be reported to the 
physician who will reconsider the advisability of administering arsenic. 
Arsenic can rarely be given to a patient with a renal disorder. No food 



8YPHILM 539 

should be given for 2 hours before the irijection, but a large drink of 
glucose containing from two to three ounces may be given half an hour 
before in order to protect the liver from the effects of the drug by filling 
it up with glycogen. 

At the time of administration some adrenalin and some pituitrin in a 
hypodermic syringe should be ready at hand in case, when the injection 
of arsenic is made, symptons of anaphylaxis should occur. 

The symptoms which may follow the administration of arsenic are: 

(a) an attack of fainting, and a nasty taste in the mouth, 

{b) a day or two after the injection there may be some slight fever, an 
urticarial rash, gastro-intcstinal disturbance with diarrhoea and vomiting, 
(c) the most serious symptoms, however, may occur a week or so after the 
injection, and these include malaise and loss of appetite, with a more or 
less marked degree of jaundice, all due to disturbance of the liver. A rash 
may be present, either erythematous or urticarial in character and in a 
few cases the skin condition progresses to one of exfoliative dermatitis. 

It is important for every nurse to realize that however slight the 
symptoms following the administration of arsenic they should be reported, 
and the patient’s urine should be tested. The substances used in the treat- 
ment of the untoward symptoms enumerated above are glucose, adrenalin 
and atropine, and proprietary preparations of sodium thiosulphate, of 
which ametox and thiostab are examples. 

Bismuth also has high treponemicidal properties, it is used in conjunction 
with arsenic. Most of the bismuthial preparations are given by the intra- 
muscular route in doses of I c.c. twice a week in the case of adults. Bismuth 
should be warmed slightly before it is injected, and after injection the area 
should be gently massaged to help in the distribution of the bismuth. 
Ulceration of the gums may arise and in this case it may become necessary 
to stop giving bismuth until the oral condition can be cleared up by good 
dental hygiene and antiseptic mouth-washes. 

Mercury, Formerly mercury was widely employed in the treatment of 
syphilis out it is now recognized that its antiseptic properties have little 
effect on the T. pallidum in the acute stage of disease and mercury is only 
employed when patients cannot tolerate arsenic. It is given by the intra- 
venous or intramuscular route in the form of collosol sulphide of mercurj^ 
Iodides. Potassium iodide and iodine are invaluable in preventing the 
formation and helping in the removal of fibrous tissue. It may be given as 
potassium iodide by mouth, in 30 grain doses three times a day, or 
Crookes’s collosal iodine may be given by the intravenous route. 

Fever therapy has during a comparatively recent period been instituted 
in the treatment of the nervous manifestations of syphilis affecting the 
nervous system — locomotor ataxia and general paralysis of the insane. 
In some cases the patient is infected with the benign form of malaria, 
which is allowed to run a short course and is then terminated by the 
administration of quinine. In other cases the temperature is raised to 
105° F. by a special short wave apparatus which is employed to produce 
the necessary degree of heat. These treatments have not yet been in use 
sufiiciently long to test their efficacy completely. (This treatment is 
described on p, 414*) 

Treatment of prenatal syphilis. Treatment of an infant should 
begin during the first week of life and be persevered with until the child 



540 VENEREAL DISEASES 

is five years of age and then, if the tests of blood serum and cerebrospinal 
fluid are negative, the treatment may be discontinued, but if positive it 
must be continued for longer. Juveniles suffering from neurosyphilis 
require treatment with arsenic and bismuth and in some cases fever 
therapy is employed (see p. 414). 


GONORRHOEA 

Gonorrhoea is a highly infectious disease characterized by an acute 
inflammation at the site of infection with widespread suppurative catarrh 
of the affected mucous surfaces. The incubation period is from two to three 
days, and this is followed by an acute stage during which the inflammation 
is marked and the discharge copious, and after a time a subacute period 
follows during which the disease becomes chronic. 

Infection is usually conveyed by means of sexual intercourse, but it 
may be acquired also by contact with infected clothing and utensils such 
as lavatory seats or the splash from a lavatory pan. Infection is very easily 
conveyed to the eyes of attendants, and the eyes of an infant may be 
infected during its passage through the birth canal. 

The glands of the affected genital tract become involved — ^in the male 
the glands are the Cowper, the prostate and urethral glands; in the female 
the cervical and uterine glands, Bartholin’s glands, and the para-urethral 
glands are easily infected. In addition the disease spreads to the urethra 
and rectum and in the female to the fallopian tubes and pelvic peri- 
toneum also. 

Acute gonorrhoea in the female is frequently characterized by vulvitis, 
urethritis and cervicitis. Bartholinitis, vaginitis, cystitis and proctitis may 
also occur. In some cases there is a good deal of local inflammation and 
copious discharge, in other cases the local symptoms arc mild, and the 
infection tends to pass unnoticed with the result that the condition 
becomes chronic and may give rise to a good deal of ill-health later. 

Treatment. The use of the sulphonamide drugs has revolutionized the 
treatment of acute gonorrhoea particularly in the male, in whom a course of 
treatment extending over 14 days, combined with daily irrigation of the 
urethra in order to prevent local complications, if possible, may result 
in complete cure. Complications must be dealt with as they arise and any 
of the glands of the urethral tract which may be the site of chronic infec- 
tion require treatment. 

One of the sulphonamide drugs, such as M & B 693 will be given for 
14 days, or longer if the patient can tolerate it. At the same time local 
treatment is undertaken in order to keep the genital area free from discharge. 
If possible it is a good plan to keep the patient in bed and under observa- 
tion but this is not always obtainable. She should, however, be told to 
rest as much as possible, particularly during her menstrual mriods, 
propped up in Fowler’s position to assist drainage. She shomd take 
frequent hot sitz baths made alkaline by the addition of sodium bicar- 
bonate, and after the bath the vulva should be well dried and powdered. 

When the discharge is profuse, local treatment is employed as follows: 

With the patient in lithotomy position, or lying on a couch with her 
legs separate, the urethra is douched by using an irrigation can, tubing 
and a pointed glass nozzle (sec fig. 175, p. 523). When the urethra is fircc 



GONORRHOEA 54 I 

of discharge a Cusco’s va^nal speculum is inserted and the vaginal sur- 
faces arc irrigated, using the same type of nozzle. Almost any mild anti- 
septic fluid may be employed — ^for example, a solution of sodium bicar- 
bonate, I drachm to a pint, is invaluable for removing mucus and this may 
be followed by an irrigation of dcttol, again using i drachm to the pint. 

After irrigation the long forceps dressed with sterile cotton wool arc 
used to apply dettol or some other antiseptic solution all over the fomices 
and the area of the cervix. This is followed by painting the same parts 
carefully, and a variety of antiseptic solutions may be used for this — 
protargol in glycerine lo per cent., mercurochrome 2 per cent., or an 
aniline dye such as violet green. Or, alternatively only a bland solution 
such as sodium bicarbonate alone is used particularly when the woman is 
pregnant. 

In acute cases a small quantity of dettol ointment, a piece the size of a 
walnut, is inserted by means of a long wooden applicator after painting 
the parts. The vagina is then packed with gauze and the speculum 
removed. This paclang is allowed to remain in the vagina for twenty-four 
hours; the patient may remove it herself and afterwards have a bath. It 
has been found that a morning and evening bath is invaluable for 
relieving the abdominal pain from which these patients invariably suffer. 
Acute cases are treated daily. Less acute cases may be treated on alternate 
days, the same procedure being followed. When the acute stage is over 
douching and irrigation are omitted but the urethra, vagina and cervix 
should be swabbed daily and painted with one of the antiseptics men- 
tioned above. 

A patient with an acute infection usually suffers from malaise, a slight 
rise of temperature, loss of appetite, headache, and she may coihplain of 
backache, due probably to infection of the pelvic peritoneum. 

Chronic gonorrhoea in the female. Any of the acute infections such as 
urethritis, Bartholinitis, vaginitis, and cervicitis may become chronic. The 
fallopian tubes, ovaries, uterus, and pelvic peritoneum may be affected 
and any of these may necessitate operative treatment. 

Tests used in gonorrhoea. Nlicroscopic examination oi smears taken 
rom ti c varioiis sites in the genital tract where the gonococcus may be 
present. Cultures of the organism are also grown and examination of the 
blood is made for the specific antibodies by means of the gonococcal 
complemenifxation test. 

Diagnosis is made by means of these tests when positive and cure is demon- 
strated when they prove negative. When symptoms have cleared up treat- 
ment ceases and the patient returns to her normal mode of life but is 
forbidden sexual intercourse for a further period of observation extending 
over six months. During this time tests are taken sifter, or towards the 
end of each menstrual period; if gonococci are lurking in any part of the 
genital tract the infection is most likely to give rise to symptoms during a 
period when the organisms will be recovered from any secretion or (Bs- 
charge collected for examination. 

In all cases of gonorrhoea the Wassermann and Kahn tests for syphilis 
are also performed as a double infection, syphilis and gonorrhoea, may 
be present. 

General advice. In discussing the mode of life that female patients with 
gonorrhoea should follow, certain points have to be taken into considcra- 



542 VENEREAL DISEASES 

tion. It must be atplaincd to tbe patient that there is danger of infection 
for other people— «ie should not fuiare a bed with her sister, for example, 
and she must be very careful not to convey infection to her eyes; 
when her clothing is soiled with discharge it should be soaked in dism- 
fectant for 6 hours before it is washed. She must realize the responsibility 
of not soiling lavatory seats and of seeing that the flush of water after 
pulling the plug cleans the pan completely, or others may be infected by 
splash. 

With regard to her diet, she should avoid all savoury foods and condi* 
ments and all stimulants, including coffee. It is advisable for her to drink 
at least 6 pints of fluid a day in order to avoid infection of the bladder; 
she must be very particular about the external cleanliness of the vulva 
and surrounding parts and pads should be changed frequently. As has 
already been mentioned it is advisable for her to have a bath twice a day 
as this helps to prevent proctitis. In some cases vaccine therapy is em- 
ployed in the treatment of chronic gonorrhoea. As a rule a stoci vaccine 
is used. It is important that a nurse should know that there is danger of 
provoking a manifestation of the catarrhal symptoms of the mucous 
surfaces by this means and she must be on the look out for this and not be 
surprised to find an increased vaginal discharge in a patient having a 
vaccine. See vaccine reaction (sec p. 327). 

Metastatic Gonorrhoea. When the organisms or toxins of the 
gonococcus are carried in the blood stream to parts of the body other 
than the genito-urinary tract, and set up inflammation of other organs the 
term metastatic gonorrhoea is employed to describe these infections. 
Examples are gonococcal arthritis, myositis and fibrositis, neuritis, includ- 
ing sciatica, cardiac lesions as pericarditis and endocarditis and eye 
lesions as iritis and conjunctivitis. 


SOFT SORE OR CHANCROID 

In distinction to the hard chancre of syphilis a soft grey-white ulcer 
acquired in a venereal manner but being non-syphilitic in origin and 
character is described as soft sore. 

It is difficult to heal and the surface is covered with a purulent offensive 
discharge. In women this sore occurs on the vulva on both sides. A 
number of sores arc usually present. 

Treatment consists in the administration of one of the sulphonamidc 
drugs and keeping the affected area clean and covered by an antiseptic 
dressing. 

PORADENITIS 

Lyrttphxigranvlorrui inguinale or poradenitis is another venereal infection. 
It appears as a small sore or ulcer, usually on the external genitalia, and 
from there the infection is carried to the inguinal lymphatic glands where 
adenitb occurs; the condition may disappear or the gland may suppurate 
and break down. 

An intradcrmal test — ‘Frei's Test’ — is used to establish a diagnosis. 

Treatment by the administration of antimony preparations and of the 
sulphonamidc drugs has proved effective, and some more intractable 
cases have been successfully treated by T.A.B. vaccine. The local area 
should be kept clean and dry. 



Chapter 36 

Pregnancy, Antenatal Care, and the Puerperium 

Ovulation, menstruation and fertilization — The symptoms and signs of pregnancy — 
Antenatal care — The toxaemias and complications of pregnancy — Labour and the 
puerperium — Puerperal sepsis — Nursing care in septicaemia 

T he changes which take place at puberty in the female organs of 
generation make it possible for a woman to conceive. The men- 
strual life occupies about 35 years, from the age of 1 2 or 1 3 to 48 
or 50 depending on climate and race, and this is followed by the meno- 
pause, which is the cessation of activity of the female sex glands. 

The ovaries are the female sex glands and the centre of the whole sex 
mechanism; if an ovary is cut across it is seen to contain holes, like a 
gruyire cheese; these are the graafian follicles, the spaces in them contain 
fluid, and minute cells line the walls of these follicles, amongst which is 
one larger cell, the egg cell or ovum. 

Ovulation is the ripening of a graafian follicle and discharge of the egg 
cell from it, which occurs once every 4 weeks, midway between the periods, 
during the menstrual life of a woman. The graafian follicle increases in 
size and is brought to the surface of the ovary; it bulges on the surface 
and eventually ruptures, the fluid in it which contains the hormone 
oestrin or folliculin flows out and the ovum or egg cell is carried out 
with the fluid into the peritoneal cavity but eventually reaches the 
fallopian tube. 

The funnel-shaped end of the fallopian tube lies in close vicinity to the 
ovary; it is lined by ciliated epithelium which is constantly moving and 
exerting a current directed outwards — that is, along the tube to the 
uterus. By this movement the ovum is attracted into the external ostium 
of the tube, and it is conveyed along into the tube where, should the ovum 
be fertilized, this normally occurs. 

Once the graafian follicle has ruptured, it becomes filled with blood 
and a number of cells grow out from its walls into this blood; these cells 
contain a yellow pigment and the mass is called the corpus luteum which 
produces the hormone progestin. 

Menstruation is the term generally employed to describe the loss of 
blood from the uterus which occurs as part of the menstrual cycle every 4 
weeks, from puberty to the menopause, and which is brought about by 
changes in the endometrium resulting in shedding of the old, followed by 
the formation of a new, membrane. The structure of the endometrium is 
peculiarly soft, in order that it may form a comfortable resting place for 
the fertilized ovum during the early development. The uterus consists of 
unstriped muscle, lined by columnar epithelium; dipping into this 
structure are tubular glands, and between these glands is a stroma of soft 
cellular tissue; this stroma is the softest tissue in the body — so soft that it is 
similar in consistence to jelly just about to set. It is from this soft tissue 
that bleeding takes place in menstruation. 

543 



544 PREGNANCY AND ANTENATAL CARE 

The menstrual cycle of 28 days consists of: 

(1) A period of 4 days* rest which follows the menstrual loss. 

(2) An interval of 10 days when the developing ^aafian follicle is 
approaching the surface of the ovary. During this time the hormone oestrin 
is active and stimulates the proliferative changes in the endometrium. 

(3) A pre-menstrual period of 10 days when, ovulation having occurred, 
the corpus luteum hormone takes over the work of preparing the endome- 
trium for the fertilized ovum and progestin stimulates the formation of 
secretory cells in the endometrium. 

(4) A destructive period follows, if the ovum is not fertilized, all the pre- 
paration of the endometrium ceases and the carefully prepared lining 
is broken down, blood escapes from the congested capillaries, the epithelial 
cells disintegrate and the menstrual flow which lasts about 4 days is estab- 
lished. 

After this, the cycle begins again and the endometrium is once more 
prepared for the next ovum, which if fertilization does not occur will 
again come to nought, but, when an ovum is fertilized, the corpus luteum 
develops and continues to produce the hormones which stimulate the 
changes which go on in the uterus, including the formation of the placenta 
upon which the development of the foetus depends. 

The control of menstruation is dependent on the activity of the ovary, 
and the function of the ovary is controlled by hormones produced by the 
anterior lobe of the pituitary body — two hormones known as Prolan A 
and B govern the ovarian cycle of activity which consists of the ripening 
and rupture of a graafian follicle and the formation of corpus luteum 
afterwards. Prolan A controls the changes occurring in the follicles during 
ovulation and stimulates the production of oestrin in the ovary. Prolan B 
stimulates the formation of the corpus luteum and the production of 
progesterone from this organ. 

The ovary produces two hormones which control menstruation: 

(1) Oestrin which is produced whilst the follicle is enlarging and pre- 
paring to rupture. This hormone stimulates the proliferative changes of 
the endometrium. 

(2) Progestin is the hormone produced by the corpus luteum after 
rupture of the follicle. It stimulates the secretory changes in the uterus 
preparing it for the reception of a fertilized ovum. 

Fertilization is the fusing of the male element of reproduction, the 
spermatozoon^ with the ovum or egg cell. This usually takes place in the 
fallopian tube, the ovum, which is non-motilc and is a round cell, being 
transmitted through the tube by the action of the ciliated epithelium which 
passes it from the external ostium, on to the internal ostium, through 
which it reaches the uterus. The spermatozoon is a motile cell, shaped like 
a tadpole with a head and a tail, and it passes up through the uterus and 
fights its way along the fallopian tube against the stream of activity of the 
cilia which is bringing the ovum along, down the tube, to meet it. On 
meeting, the head of the spermatozoon penetrates the ovum and the tail 
drops off; the two cells fuse, but no change takes place in the ovum until 
growth commences. 

Cell division commences and the fertilized ovum passes along the 
fallopian tube into the uterus, which is prepared with its soft lining to 
receive it. Various changes now take place and different cells arc formed, 



PREONANCY AND ANTENATAL CARE 545 

some going to the construction of the foetus while from others the placenta 
and membranes arc formed. 

THE SIGNS AND SYMPTOMS OF PREGNANCY 

A woman is said to be pregnant when she has conceived; the uterus 
will retain the growing foetus for lo lunar months or 280 days, which is 
the duration of pregnancy. To calculate the date the baby may be 
expected to be born, add 9 calendar months and 5 days from the last day 
of the last menstrual period. This reckoning is correct within 2 or 3 weeks. 

The symptoms and signs by which pregnancy may be determined 
are divided for convenience into those which appear during the first 3 
months, and those seen later. 

During the first 1 2 weeks ^ amenorrhoea is considered to be a sign of preg- 
nancy, provided the woman has previously menstruated regularly and 
that there is no other cause of amenorrhoea, such as the onset of the 
menopause, anaemia or other illness. 

Morning sickness. This usually occurs from the sixth to the sixteenth 
weeks, and is thought to be due to chemical changes in the maternal 
blood owing to the passing into the maternal circulation of waste products 
from the foetus and the placenta. It may be relieved by taking a cup of 
tea and a biscuit before rising in the morning. 

Breast changes commence about the sixth week, when the breasts are full 
and tender. By the twelfth week the breasts arc firmer and some mucus 
secretion is present. The nipples become erect and the areola, dark in tint 
with visible veins, appears beneath the surface of the skin. By the sixteenth 
week, little nodules, called Montgomery’s follicles, appear around the 
area of the nipple and by the twentieth week the secondary areola appears. 

Progressive enlargement of the uterus. The uterus can first be felt above the 
symphysis pubis at the sixteenth week. Before this time examination 
would reveal softening of the cervix and a little later the cervix and vagina 
become discoloured blue. 

Frequency of micturition is complained of during the first 12 weeks of 
pregnancy. 

Intermittent uterine contractions may be felt, after the sixteenth week. 
Quickening occurs from the eighteenth to the twentieth week, when the 
mother feels the child moving. A number of other signs can be determined 
on examination of the patient by a doctor or midwife; foetal heart sounds 
can be heard after the twenty-fourth week. 

The Aschheim^Z^ndek test is positive from a time which may vary from 
the fourth to the sixth week. The urine of a pregnant woman contains a 
substance not present in non-pregnant women. If a small quantity of the 
urine is injected into immature white mice, after a few days developmen- 
tal dianges will be found to have taken place in the generative organs of 
these animals, and these changes, if they are found, are diagnostic of 
pregnancy. 

The Friedman Test is similar. It is performed on young rabbits. 

ANTENATAL CARE 

Antenatal care is undertaken in order to assist a woman through 
pregnancy and to avoid and treat any diseases or abnormal conditions 



546 PREGNANCY AND ANTENATAL CARE 

which may arise in order to ensure a normal uncomplicated labour and 
puerperium. Every married woman should be advised cither to consult 
her own doctor or to attend one of the many excellent antenatal clinics 
provided, as soon as she knows she is pregnant, for examination, observa- 
tion, advice and treatment. 

The date of her first attendance will be recorded and the date of her last 
menstrual period^ and the possible date of the expected confinement will be esti- 
mated. 

History. If previous pregnancies have occurred, she will be questioned 
as to whether these were normal or complicated and whether she has ever 
had premature labours or miscarriages; she will also be asked whether 
she has had any serious illnesses — ^scarlet fever, tonsillitis, rheumatism 
and chorea being specially mentioned — and she will be asked whether 
she has ever had any surgical operations or met with any serious accidents. 

Examination will follow, the condition of the heart and lungs being 
investigated and her blood pressure taken; she will be asked whether she 
has any vaginal discharge, and, if so, smears may be taken in order to 
determine the cause of this. A specimen of urine will be tested. As regards 
the patient’s general condition, she will be closely inspected and ques- 
tioned; her mouth, teeth and tonsils will be examined; the temperature, 
pulse and respiration rate, and her weight will be recorded; the colour of 
the skin and of the mucous membranes will be considered in order to 
note whether there is any indication of anaemia; she should be asked 
whether her ankles swell at night and whether she gets breathless on 
exertion or easily tired; she will also be asked about her appetite, and 
whether she has her bowels open regularly, and how she sleeps. Her 
breasts will be examined and particular note made of the condition of the 
nipples. 

The midwife or doctor will examine the abdomen and vulva, but a 
vaginal examination is not usually undertaken early in pregnancy unless 
some abnormal condition is suspected. 

Frequency of examination. At the first visit the patient is instructed how 
often she is to attend; it is usual for attendance to be made once a month 
during the first 6 months of pregnancy, once a fortnight during the next 2 
months and every week during the last month. At each visit the urine 
should be tested for albumin, the blood pressure taken and recorded and 
in certain cases the weight, and the patient carefully questioned with 
regard to her general health and comfort. 

Anti^natal advice. Many books are procurable on this subject and it is 
treated in great detail; the main points on which it is essential that a 
woman should be clearly advised are as follows: 

Diet should be light but nourishing, plenty of fish and some chicken 
may be taken, and all dairy produce, including a pint of milk a day. Red 
meat should be taken but sparingly — ^if the woman feels that she would 
miss this very much she may have a little once a day, but it would be 
better if she could have one day a week without taking red meat. Highly 
spiced foods, hot sauces and stimulants, and strong tea and coffee are 
inadvisable, though she may have a little weak tea or coffee twice a day. 
If she is in the habit of taking alcohol and it would be a privation to give 
il>up entirely, a litde may be taken once a day. Plenty of green vegetables 



ANTENATAL CARE 547 

and fresh fruit should be taken also; and at least 3 pints of such fluids as 
lemonade and orangeade each day, in addition to the ordinary drinks at 
breakfast and tea time. 

Action of bowels. A pregnant woman must have a good action of the 
bowel every day. She should not take aperients except laxatives and 
lubricants such as senna tea and paraffin, or one of the petrolagar pre- 
parations. 

Rest and sleep. As far as possible fatigue should be avoided — a pregnant 
woman should always have from 8 to 9 hours in bed at night and she 
should also rest for 15 minutes before the two main meals of the day and 
for one or two hours after the main meal. 

Exercise. Moderate exercise is valuable but the patient must not get 
tired and she should avoid sudden strains and violent jerky movements. 
Open air exercise is to be recommended, but every woman will have to 
consider this question for herself — for example, a woman who does most 
of her own housework, and walks about doing the shopping, does not 
need a 3-mile walk every afternoon as well. 

Clothing should be light and warm, tight bands round waist and breast 
being avoided, and a pregnant woman will find it most comfortable if her 
clothing is suspended from the shoulders as far as possible. High heels 
should not be worn, as they throw the body weight forward, with the 
result that the woman develops a lordosis in an attempt to balance her 
own weight and this causes backache. 

A bath daily is advisable, and the patient should be told to wash her 
breasts and nipples thoroughly whilst in the bath and to train her nipples 
to be erect if they are at all inclined to retraction, though her handling 
of them should never be painful. She should be taught that the nipples 
contain the openings to all the milk ducts and that the surface should be 
gently rubbed free of old epithelium and wiped dry with a slightly rough 
towel to stimulate the circulation. 

It should always be impressed on a pregnant woman that if she feels 
unwell, gets a bad headache, feek sick and disinclined for food or has any 
other symptoms of malaise, or any loss of blood, she should visit her doctor 
at once and not wait until the next visit is due. 

THE TOXAEMIAS AND COMPLICATIONS OF 
PREGNANCY 

In pregnancy, a number of complications may arise, some of these 
known as toxaemias are thought to be due to the passing by the child of 
all its waste products through the placenta into the maternal circulation, 
so that the excretory organs of the mother have a double load of waste 
matter to eliminate. 

The three most serious toxaemias are pernicious vomiting, pregnancy 
albuminuria and eclampsia. 

Morning sickness, if excessive, is abnormal and should be considered a 
complication. 

Neurotic vomiting. In these instances, although the woman vomits a 
great deal she does not appear ill, and does not lose a g^t deal of weight, 
nor become dehydrated. The cause of this type of vomiting is not known. 

Pernicious vomiting, though serious, is fortunately rare. When it 
occurs it is during the early months of pregnancy. The patient vomits 



548 PREGNANCY AND ANTENATAL GARB 

frequently and does not retain any nourishment or fluid, and consequently 
becomes gravely ill. 

Pregnancy albuminuria. When this toxaemia occurs, it arises during 
the latter half of pregnancy. It is far more common than pernicious 
vomiting. The symptoms include albuminuria; the urine may be loaded with 
albumin, the quantity is diminished and the urine may contain casts. 

The blood pressure rises, the systolic pressure may rise to 170-180 and the 
diastolic to 90 or over. 

The patient is anaemic; she is pale and puffy as oedema occurs; the eye- 
lids, ankles, hands and vulva swell first. There is headache, and usually 
sleeplessness; sometimes visual symptoms arise, such as diplopia, dimness of 
vision, flashes of light before the eyes. If jaundice and vomiting occur, 
these symptoms are considered as indications that the liver is becoming 
affected by the toxaemia. 

Medical treatment. Pregnancy albuminuria is a pre-eclamptic state (see 
below), but if medical treatment is carried out early the danger of 
eclampsia may be averted. Such a case is often admitted to the medical 
wards of a hospital for suitable treatment. 

Absolute rest is of first importance. A preliminary period of starvation is 
carried out, and only fluids containing glucose are administered for the 
first 24-36 hours. The bowels should be well opened with salines and jalap in 
order to produce watery stools and so relieve the oedema and also facilitate 
the work of the kidneys. Large doses of alkalis are administered, as preg- 
nancy toxaemias are thought to be associated with decreased alkalinity 
of the blood. Drugs are ordered for the relief of headache and sleeplessness. 

If improvement takes place the patient may be given a littie food; 
the diet should be light, bread and butter, a little fruit and green vegetables 
may be given, and this treatment should be continued for several weeks. 

The nursing duties include keeping a strict record of the fluid intake 
and urinary output, testing a specimen of urine each day, and taking and 
recording the blood pressure twice a day — morning and evening. 

Eclampsia is the name given to fits which occur during the latter half 
of pregnancy, and also during the puerperium. The condition is associated 
with rabed blood pressure and albuminuria and is thought to be due to 
absorption of toxins from the placental site which injure the kidneys, as 
in pregnancy albuminuria, and also injure the brain cells, resulting in fits. 

A patient admitted with eclampsia will usually have a history of the 
symptoms already described above. In pregnancy albuminuria, her urine 
will be markedly diminished and contadn a lot of albumin, and oedema 
will be present. She may have had several fits. 

An eclamptic fit is epileptiform in character and occurs in similar stages 
— (i) A premonitory stage luting perhaps 15 seconds; (2) a tonic stage, lasting 
about 30 seconds, when the muscles are ri^d; (3) a clonic stage when 
convulsive movements occur, beginning at the face and passsing to the 
body; this stage may last for i or 2 minutes. The fourth stage (4) is of 
coma accompanied by stertorous breathing which may cither last a few 
minutes or go on for many hours or days. 

Treatment. Eclampsia is a very serious condition, the mortality being 
high, and the patient needs the same care as described in epilepsy, during 
a fit. Medical treatment is similar to that described for pregnancy albumin- 
uria; the iirine should be frequently tested and the blocm {H'esmure taken 



COMPLICATIONS OF PREONANCY 549 

durii^ the illness. The patient must be kept quiet in a darkened room, 
sedatives such as morphia, and bromides being given and the severity 
of the fits when they occur lessened by the administration of chloroform 
inhsdations. 

Miscarriage is the premature termination of pregnancy any time 
before the twenty-eighth week. The termination of pregnancy after that 
period is called premature labour; the child is viable after 28 weeks, but 
the longer labour can be delayed after this date the better chance the child 
has of hving. A premature baby of 32 to 34 weeks has a better chance than 
one of 28 to 30 weeks. 

There are a number of natural causes of miscarriage, and it is a fairly 
common complication of pregnancy — for example, a woman who has had 
five or six children may quite ordinarily have had one miscarriage. 

Amongst the causes mentioned are — fibroid tumour of the uterus; the 
formation of bloodclot in the uterus; an unhealthy endometrium; the 
presence of a dead ovum. Any foreign body in the uterus will cause it to 
contract and probably result in expelling the foetus. 

A dead ovum may be caused by certain diseases of the mother such as 
chronic nephritis, or any pyrexia or acute illness. 

Symptoms of miscarriage. A miscarriage is really a miniature labour, and 
it may occur a few days, some weeks or sever^ months after pregnancy 
began. A very usual history is that the woman has missed menstruation 
for 2 or 3 months; she then begins to bleed from the uterus, and this is 
accompanied by abdominal pain, followed by a stronger flow of blood, 
and the products of pregnancy are expelled from the uterus. 

Treatment depends on whether the miscarriage is complicated by bleed- 
ing or not. If it is not the duties of the nurse are to keep the patient in bed, 
to sec that she remains quiet and that all pads are preserved for inspection 
and to note whether any of the products of pregnancy are discharged 
and to save them. If there is bleeding it may go on quietly for hours, 
resulting in marked anaemia, and in such a case the patient must be 
treated for shock and the nurse should make all preparations for taking 
her to the operating theatre. 

The after em’e includes observation of vaginal discharge, and obser- 
vation of the temperature and pulse for fear sepsis should complicate the 
miscarriage. 

Antepartum haemorrhage means that there is bleeding from the 
uterus after the child is viable, that is during the latter part of pregnancy; 
haemorrhage occurring earlier is described as a threatened miscarriage. 
Antepartum haemorrhage, which is very serious, occurs when the placenta 
becomes separated from the wall of the uterus and there are two main 
reasons to either of which it may be due — (i) the placenta may be unhealtfy 
and therefore not firmly attached to the uterine wall, so that it comes off 
and bleeding occurs into the uterus; (2) is described as placenta praevia, 
meaning that instead of the placenta being on the upper part of the wall 
of the uterus, as is normal, it is situated on the lower part, below the baby; 
and, as the lower part of the uterus widens and spreads towards the end of 
pregnancy, it tends to cause separation of the placenta, resulting in serious 
bleeding. 

Tlie treatment of ankpartum haemorrhage requires the services of a skilled 
obstetrician, but if a nurse is present she may, before his arrival, try to 



550 PREGNANCY AND ANTENATAL CARE 

keep the patient very quiets elevate the fcx>t of the bed on which she lies 
on a chair or bcdblocks, and prepare for giving a douche and for plugging 
the vagina. 

Other complications which may arise include cameous mole, vesiadar 
mole, retrovertea gravid uterus, chorea and insanity. Less serious complications 
are constipation, cramp 4 ike pain in the legs, oedema of the legs, varicose veins, 
pruriHs and pyelitis. 

Pyelitis occurs about the fifth month; it is fairly common and is thought 
to be brought about by pressure of the uterus on the ureters, occurring 
at the period during pregnancy when the uterus fills the pelvic basin, 
and before it rises out of the pelvis. It is thought that the pressure on the 
ureters causes stagnation of the urine in the pelvis of each kidney and gives 
rise to pyelitis; it is commoner on the right side than on the left. The 
symptoms and treatment of pyelitis have been described on p. 402. The 
prognosis in pregnancy is good, the condition responding to treatment 
and usually clearing up in a week or two. 


LABOUR AND THE PUERPERIUM 

The stages of labour. The nurse in training in a general hospital will 
not be expected to attend a woman in labour, but she should be able to 
recognize the symptoms of the onset of the first stage as she may have to 
nurse women who are pregnant in the medical and also in the gynaeco- 
logical wards. 

The first stage of labour begins with the onset of labour pains and lasts 
until the cervix is fully dilated. The pains are due to the contractions of 
the uterus, and dilatation of the cervix is brought about when the uterus 
squeezes its contents down against the cervix. 

The onset of labour is indicated by pain in the back, associated with hardening 
of the uterus under the anterior abdominal wall. Other points to note are — that 
labour pains are intermittent, not continuous, and that they tend to 
become stronger and more frequent. In addition there may be a blood- 
stained mucoid discharge from the vagina which begins with the onset 
of the pains, and if there is an escape of fluid from the vagina there is no 
doubt about the onset of labour. Nurses should not attempt to treat the 
symptoms mentioned, but should observe the character of the pains and 
send for a doctor at once and be able to give him a lucid account of the 
woman's condition. 

The second stage of labour lasts from the time the cervix is fully dilated, 
to the birth of the baby. 

The third stage is from the birth of the baby, until the placenta, which 
separates, is expelled from the vagina. 

Dangers and complications. Obstructed labour is probably the most 
striking danger to be feared, and it may result cither because the brim 
of the bony pelvis is too small for the head of the child to enter the pelvis, 
or because the head of the child is abnormally large. 

A contracted pelvis may be due to rickety deformity, or to some develop- 
mental error less easily diagnosed. 

Medpositian of the child in the uterus is another cause of dUfficult or ob- 
struct^ labour. The normal position is with the child's head dowiH fuUy 



LABOUR AND THE PUERPERIUM 55 1 

flexed on the sternum, and the spine lying against the mother’s anterior 
abdominal wall. 

Post-partum haemorrhage is another serious complication of 
labour, and it is due to bleeding from the placental site after a portion 
of the placenta has separated. Normally, after the child is born, the 
uterus which has been contracting powerfully to expel the child rests 
for a little and then contracts again to expel the placenta. The blood 
vessels of the placental site are closed by the uterine contractions after 
separation of the placenta. If the uterus does not contract sufficiently to 
close these vessels the patient may bleed to death in a few minutes. 

Post-partum haemorrhage is described as primary when it occurs 
immediately after the birth of a baby and secondary when it occurs hours, 
days or even weeks later. At the time primary post-partum haemorrhage 
occurs the midwife will be in attendance, but it may sometimes happen 
that a nurse who is not a midwife may have to deal with a patient suffering 
from secondary post-partum haemorrhage. In such a case bleeding may 
not occur in alarming quantities but as a continuous steady loss; the nurse 
should send for doctor and midwife and in the meantime, if she has 
pituitrin at hand she should give 5 units hypodermically; if not, and she 
has any preparation of ergot, she should give this, though it will not act 
as rapidly as pituitrin. The foot of the bed should be put on high blocks; 
shock relieved by applications of heat, fluid should be given by mouth 
and saline per rectum; if bleeding continues and the doctor and midwife 
do not arrive the nurse should give a hot vaginal douche. The patient 
must be reassured and kept lying quiet and still. 

Ectopic gestation, tubal gestation or extra -uterine pregnancy 

may occur. The commonest site for this is the fallopian tube, and the 
pregnancy can proceed here for from aj to 3 months, provided that it is 
lodged in the outer part of the tube, which is the widest part — the tube is 
stretched by the growing foetus and in the generality of cases it ruptures, 
and this is the danger to be feared. 

Symploms and signs of ruptured ectopic gestation. As the result of rupture of 
the tube, bleeding will occur and the symptoms present depend on(i) 
whether the bleeding is slight, when it may go on continuously for hours, 
until the woman notices she is getting weaker and probably has some 
abdominal pain; or (2) whether it is serious and sudden, and the appear- 
ance of the woman that of an acute abdominal catastrophe. When bleed- 
ing is very serious the patient becomes faint and collapsed and the skin 
is blanched. Her pulse is rapid and temperature subnormal. On examin- 
ation the abdomen will be found to be tender but not much distended. 
Blood is discharged from the uterus. This patient is dying of loss of blood, 
and she requires immediate blood transfusion for relief of anaemia and 
an operation to stop the bleeding, the injured tube being either stitched 
up or removed according to the degree of damage found on opening the 
abdomen. 

Many less serious cases are seen, but in all cases it is necessary to note 
the character of the discharge and to inspect all pads for any portions of 
membrane as these may be the decidua. 



552 


PREGNANCY AND ANTENATAL CARE 


PUERPERAL SEPSIS 

The puerperlum is the period which follows labour during which the 
wounds left by the separation of the placenta, lacerations of the cervix 
and possibly tearing of the perineum, heal. Although the raw surface left 
after separation of the placenta closes a good deal by subsequent contrac- 
tions of the uterus, there is nevertheless still a considerable surface left 
which has yet to heal. 

Causes. A variety of organisms may give rise to puerperal sepsis, either 
staphylococci, streptococci or bacilli coli may be the cause. Streptococcal 
infection of the placental site is the most serious type, accounting for 50 per 
cent, of the cases of maternal mortality in this country. Efforts are constantly 
being made to prevent it, and one of the greatest difficulties is to know 
how the organisms reach the site. 

At the present time in hospitals labour is conducted like a surgical 
operation: the labour room is like an operating theatre; everything used 
is aseptically prepared; the obstetrician and nurses prepare themselves 
as if about to assist at a major operation and wear sterile gowns, gloves 
and masks; the vulva and skin round the perineum is shaved, the skin 
of the patient’s buttocks and thighs being specially prepared. All these 
precautions are taken in order to prevent the possibility of infection from 
those in attendance, and to prevent the conveyance of germs into the 
vagina from the patient’s skin by the hands of the operators or from 
the utensils used. In spite of all precautions, however, a comparatively 
lar^e percentage of women do become septic, and it is thought that the 
causative germs must be from the woman herself, either on her skin or 
in her tissues in the form of some septic focus, or from some person with 
whom she has been in contact — such as a child with a chronic nasal 
discharge or someone with septic tonsils — and it is particularly important 
that the pregnant woman should not be in contact with anyone who has 
an infected throat or nose during the weeks immediately preceding her 
delivery. 

Similar precautions continue to be carried out after delivery, the woman 
being nursed with'aseptic precautions and even the bedpans sterilized 
in hospitals. 

In addition to the tyjje of organism, its vindence and its mode of access 
to the placental site, certain' predisposing causes must be remembered, 
including lowered resistance of the patient for any reason, and antenatal 
care aims at preventing this. The resistance of the woman may be lowered 
by an abnormal or protracted labour in which her liability to infection 
is further increased by the necessary handling and possibly by the use of 
instnunents. Bleeding during and after labour, the retention of clots or of 
placenta, anything jffiat causes delayed or incomplete involution of the 
uterus — any or all of these may lower her resistance to the invasion of 
sepsis-producing organisms. 

VARIETIES OF PUERPERAL SEPSIS 

Any rise of temperature occiuring during the puerperium is considered 
to be an indication of sepsis. Puerperal pyrexia is a term used to des- 
cribe the condition which exists whenever the wonoan’s temperature rises 
to ioO'4‘’ F., or reaches that degree twice within 24 hours. 



VARIETIES OF PUERPERAL SEPSIS 553 

Sapraemia. Puerperal sepsis gives rise to a toxaemia, more or less 
grave according to the virulence of the infection. At first the condition 
usually remains local, but the organisms multiplying at the site of infection, 
and flouring toxins into the blood stream, give rise to sapraemia. 

The onset of sapraemia usually occurs about the third day, the temperature 
rising from ioi° to 103® F. and the pulse rate increasing proportionately. 
The symptoms which accompany the febrile state are present, such as 
thirst, a dry mouth, scanty output of urine and constipation; there is 
general discomfort with headache, malaise and sleeplessness. The lochia 
becomes profuse and is offensive. 

{Lochia is the term used to describe the discharge from the vagina, 
due to drainage of the uterus following labour. Lochia is at first red and 
bloodstained, then becomes paler and pinkish, until at the end of about 
9 or 10 days it clears altogether. There should never be any offensive 
odour, and the lochia should always be watery in character.) 

Local treatment which will be employed consists in drainage of the uterus 
by the injection into it of glycerine. This treatment was introduced by 
the late D. Remington Hobbs. A graduated uterine terminal-eyed catheter 
(see fig. 54 , p. 1 70) is inserted into the os uteri by means of an introducer, 
a record syringe is attached to the end of the catheter and glycerine 
slowly injected. The patient is nursed in Fowler’s position. 

Septicaemia is a more serious form of puerperal sepsis, and is described 
as puerperal septicaemia. The onset is sudden — the most serious cases begin 
on the first or second day — ^with a rise in temperature of from 103° to 
104° F., rigors occur, the skin is hot and there is often profuse sweating. 
The pulse is rapid. T^e mouth is dry and parched, the tongue furred and 
sordes collect on the teeth, the lips become cracked and sore. The appetite 
is poor, but the patient may ask for special dishes saying, for example, she 
would like a boiled onion or some bacon and eggs. There may be nausea 
and vomiting. 

The urine is scanty and high coloured, diarrhoea or constipation may 
be present. Headache is usually present and the patient finds it impossible 
to sleep, she becomes more and more prostrated and develops delirium. 
The milk is suppressed and the lochia may be scanty and offensive or even 
entirely suppressed. As the days pass the patient becomes very weak and 
emaciated and has a tendency to develop bedsores. 

In appearance her skin is grey and toxic, she has a malar flush and her 
eyes may be bright. A characteristic feature of the most severe cases is 
that they declare they are all right and do not feel ill — they are unduly 
cheerful. 

Serious signs are persistent vomiting and marked diarrhoea, rigors 
occurring frequently, hiccup and jaundice, intractable insomnia and 
weakness of the pulse. 

The prognosis is grave, and the earlier the appearance of the symptoms 
the graver is the condition. Very serious cases begin to be ill on the first 
or second day of the puerperium; milder cases on the third, fourth or fifth 
day. 

Pyaemia may succeed septicaemia. In this condition the blood is liable 
to clot in the veins and portions of this friable infected bloodclot, breaking 
off, pass through the circulation and becoming arrested in various organs 
give rise to t^ formation of abscesses. In grave cases multiple abscesses 



554 PREGNANCY AND ANTENATAL CARE 

fonn in the subcutaneous tissue, and in the joints, liver, lungs and 
brain. 

The condition of pyaemia is characterized by very grave prostration 
and symptoms similar to those of septicaemia; the occurence of rigors is 
frequent. The prognosis is grave. 

Localized spread of infection may also occur. Pelvic cellulitis is due to 
spread of sepsis to the tissues and organs in close relation to the infected 
uterus and cervix. This does not usu^ly happen until the second week of 
the puerperium. 

Spread of infection upwards from the uterus may give rise to salpingitis, 
pyosalpinx, ovarian abscess, and pelvic peritonitis. 

Thrombo -phlebitis of the fenaoral vein, which is also called 
white leg and phlegmasia alba dolens, is due to spread of infection from the 
pelvis. The lymphatics are infected, and this results in blockage of the 
passage of lymph, which exudes into the tissues so that the limb becomes 
swollen, with a characteristic marble-white shining appearance. There 
is pain over the affected vein, a rise in temperature and increase of pulse 
rate. This acute condition lasts about 2 weeks, but the swelling of the limb 
will persist for from 5 to 6 weeks. 

Treatment is to immobilize the limb, which should be elevated on a 

E illow, carefully supported and protected from the weight of bedclothes 
y a cradle. Applications of glycerine of belladonna and fomentations 
are ordered for the relief of pain and swelling. 

The diet should be low and the bowels active, the patient being kept 
as quiet as possible, free from anxiety and not allowed to move more than 
is absolutely necessary as there is danger of a pulmonary embolism, 
particularly during the first two weeks when the condition is acute. 

THE NURSING CARE AND TREATMENT OF SEPTICAEMIA 

The nursing of a case of puerperal septicaemia does not differ from that 
of any other case of septicaemia, except in so far as vaginal pads must be 
carefully inspected for the amount and character of any lochia, and it is 
advisable to have the patient in Fowler’s position so that drainage from 
the uterus is made easier. 

The aim of nursing care is to raise the resistance of the patient by the 
provision of a good liberal nourishing diet, -with plenty of drinks containing 
glucose in addition, so that easily assimilated nourishment is readily 
available and that plenty of fluids may be provided in order to maintain 
the balance of fluid in the body and so lessen the toxaemia. 

The patient should be nursed in the open air, and made as comfortable 
as possible, so that discomfort is minimized and relieved, and in this way 
rest is obtained and the maximum of sleep made possible. 

Diet. In many instances a case of puerperal septicaemia particularly 
is found to have a very dirty mouth when admitted to hospital for treat- 
ment. The best way to deal with this condition is to give the patient fluids 
for 2 or 3 days — lemonade and barley water sweetened with a little glucose, 
plain water and soda water and a little beef tea; as the condition of the 
mucous lining of the stomach improves the mouth becomes cleaner and 
the diet may be increased by adding jellies, clear soups, tea and dry toast, 
and after a day or two fish and chi^en cream and stewed fimit, gradually 



CARE AND TREATMENT OF SEPTICAEMIA 555 

introducing a fuller diet with the addition of a little white wine or other 
stimulant. 

A four-hourly temperature record should be made and the pulse noted 
frequently; watch must be kept for the onset of rigors. During a rigor the 
temperature should be recorded every half-hour at least, so that its rate 
of rising is noted and the patient should be sponged if the fever reaches 
105^ F., or earlier should the symptoms of toxaemia, indicated by head- 
ache, restlessness and delirium be straining the resources, and lowering 
the resistance of the patient. 

The skin will act profusely after a rigor and the patient should be 
sponged with warm or hot water as the temperature declines; a warm 
drink and dose of stimulant may be given as the patient will be consider- 
ably weakened by having a rigor, and careful nursing may induce the 
sleep which is the best mode of rest. 

Throughout the illness the nurse must remember the necessity of sleep. 
Patients with septicaemia are at times bright and talkative, and so in- 
clined to develop restlessness and delirium, and she should do all in her 
power to keep these patients contented and peaceful, free from the sense 
of worry and anxiety, which is so readily contributed to by irritation and 
discomfort. In many cases hypnotics will be ordered. 

The skin should be sponged night and morning, as this is soothing; in 
some instances the nurse will find the use of hot water most soothing and 
helpful, in others the patient will be made most comfortable by sponging 
with cooler water. The emaciation which exists tends to predispose to the 
formation of bedsores, but these must be prevented; frequent passage of 
stools makes the skin around the anus tender and sore. Using olive oil or 
paraffin swabs to clean the patient after the use of a bedpan may be 
necessary. 

Many cases of puerperal septicaemia are found to have retention of urine^ 
and it is most important to observe the slightest fullness above the sym- 
physis pubis indicating this condition; it should be relieved by catheteri- 
zation. Some patients thought to be incontinent may be found to have a 
full bladder, the apparent incontinence being a dribbling of overflow from 
a very distended bladder. 

Treatment by the sulphanilamide preparations has revolutionized the prognosis 
of cases of puerperal septicaemia and reduced the mortality very con- 
siderably. For an outline of the administration of this method of treatment 
(see pp. 327-31), 



Section Six 


Surgical Nursing and Elementary 
Surgical Technique 


Introductory 

S urgery is described as a branch of medicine; it deals with the treatment 
of conditions brought about by malformation, deformity, tumours, 
injur)% infection and inflammation. Surgery is both an art and a 
science; it is a very old art, but the science of surgery is of comparatively 
recent development. Dexterity in manipulative and operative surgery in 
the middle of the last century could not make up for the lack of anaesthetics 
and antiseptics, and skill in the performance of an operation had no relation 
to its ultimate success as the life of the patient was imperilled by serious 
shock and dangerous sepsis, known and described as hospital gangrene. 

By means of these two important discoveries of the nineteenth century 
— anaesthetics and antiseptics — a surgeon can undertake and bring to a 
successful conclusion operations and manipulations which would otherwise 
have been impossible. 

The principles of the practice of surgery include the provision of rest and 
treatment by passive and active movement; the application of soothing 
and stimulating remedies, the provision of free drainage in septic con- 
ditions, manipulative and operative technique, and the difference be- 
tween domestic and surgical cleanliness. In his care of injured and diseased 
tissues a surgeon requires to be familiar with the normal processes of 
repair as he is constantly called upon to make decisions as to whether a 
soothing or stimulating remedy is called for; whether rest or manipulation 
is indicated, the necessity for operative interference, and whether in a 
given case an extensive procedure may be undertaken or whether he had 
not better be content with lesser measures. 

Nursing is closely allied to surgery, and has developed alongside of it. 
Florence Nightingale first recognized the need for cleanliness in surgical 
wards, and the nurse of today puts Miss Nightingale’s teaching into practice. 
She must understand the meaning of rest, passive and active movement; 
attempt to see what a surgeon is aiming at when he applies healing remedies, 
splints, plaster, or extensions, or incises and drains septic tissues, the effect 
he desires to obtain by manipulative surgery, and to follow the procedure 
he adopts in an operating theatre and be able to assist, by her intelligent 
nursing care, the recovery of the patient after an operation. 

Surgical nursing provides a vast field of interest and wide experience in the 
general care and treatment of sick persons, including as it does acute infec- 
tions, chronic states of illness, accidents and emergencies, and in addition in 
the complications of surgical conditions includes grave cardiac, respiratory 
and renal disease and disability. A nurse in a surgical unit may consider 
she is gaining not only surgical but general medical experience also. 

556 



Cfmpter 37 

Infection — Inflammation — Haemorrhage — Ulcers 
— Tumours and Cysts 

Surgical infection — Gas gangrene — Ir^ammation: symptoms, terminations and 
treatnunt~Haemorrhage : causes of bleeding, general classifcation, symptoms 
associated with bleeding, means used in treatment — Ulcers — Tumours and cysts: 
classification of tumours, differences between simple and malignant tumours 

I nfection is the successful invasion of the body by disease-producing 
organisms. The commonest modes of infection are (i) pulmonary, by 
droplets in moist air; (2) intestinal, when bacteria are swallowed with 
food and water; (3) inoculation, either through a mucous surface or an 
abraded skin, or by means of some biting insect. 

Surgical infection is described as local or general. Examples of local 
infection include boils, in which inflammation occurs in the hair follicle; 
this becomes surrounded by dense tissue which deprives the centre of its 
circulation, resulting in a slough, commonly known as the ‘ core’ of the boil. 

Carbuncles are areas of localized inflammation in the deeper parts of the 
skin and subcutaneous tissue. The back of the neck is a common site for 
carbuncle. It is more serious than a boil, as ulceration occurs and large 
sloughs are formed, and infection may spread by means of the lymphatics, 
giving rise to general septicaemia. 

Small subcutaneous abscesses may occur as the result of infected insect 
stings, infected abrasions and infected haematoma. An abscess is a col- 
lection of pus in a cavity. Common sites of abscess are the tonsils, ap- 
pendix and mastoid cells. 

Cellulitis is inflammation of the connective tissue and fascia lying be- 
neath the skin and separating the different layers of muscles. It results in a 
brawny swelling, there is a very diffuse area of infection and septicaemia 
may result. 

The organisms which commonly give rise to surgical infection are those 
which are always present on the skin, staphylococci, streptococci and 
bacilli coli. The organism producing erysipelas comes from one of the 
streptococcal groups. Other rarer surgical infections due to spore-forming 
organisms include anthrax, gas gangrene and tetanus. (A spore is a small 
oval body formed in certain bacilli which renders them resistant to des- 
truction under adverse circumstances. Spores are difficult to destroy.) 

Syphilis and gonorrhoea also come under the heading of surgical 
infections (sec ch. 35.) 


GAS GANGRENE 

As the name implies, this acute surgical infection is characterized by 
gangrene or necrosis accompanied by the formation of bubbles of gas in the 
affected subcutaneous tissue. 

The causal organism belongs to the Clostridium group which are spore- 
forming anaerobic organisms and include the CL welchii. Cl. septique and 

557 



558 IMPEGTIOK — INFLAMMATION 

CL oedematiens. Infected wounds, such as war wounds, provide an ideal 
medium for the growtli of these organisms. 

The onset of gas gangrene is that of an acute rapidly spreading infection. 
Muscle tissue is most commonly involved, the wound becoming covered 
with an offensive exudate having a characteristic odour, which is likened 
to the smell of acetylene gas. Local swelling of the tissues occurs, and when 
a limb is involved the entire limb becomes oedematous. Crepitation due 
to escape of gas into the subcutaneous tissue is present. In advanced cases 
the skin over the infected area is mottled dusky-brown, and purplish- 
black patches appear which may be covered with blebs and bullae. 

Treatment. Surgical incision of the wound, including careful removal 
of all foreign bodies, and free drainage of the tissues is essential. Poly- 
valent gas gangrene antitoxin is given in recommended doses to neutralize 
the toxin; and the administration and also the application locally of 
sulphonamidesy to act as a bacteriostatic agent, arc employed. 

General Surgical Infection. A general infection may be caused by 
saprophytic organisms giving rise to fermentation and putrefactive 
changes; or by parasitic organisms producing pyogenic infection, such as 
staphylococci, streptococci, b. coli, pneumococci and gonococci. The 
varieties of a general infection may be classified according to severity: 

Sapraemia. When local changes brought about by the products of 
fermentation occur. 

Septicaemia, When the causative organisms circulate in the blood stream 
and produce extensive general disturbance. 

Pyaemia, When the character of the blood is altered, clotting takes place 
and infected blood clot gives rise to the development of metastatic abscesses 
in different parts of the body. 

(For details of the condition of a patient suffering from septicaemia, 
see p. 554.) 

INFLAMMATION 

Inflammation is the reaction of healthy tissues to injury, and the 
reaction is characterized by a series of changes upon which the symptoms 
depend. 

Causes. Inflammation may be due to a variety of causes, but bacterial 
invasion may be considered the commonest cause, other causes including 
mechanical, thermal and chemical injuries, excessive heat and cold, and 
electrical injuries including exposure to high tension current and X rays. 

The changes taking place in the tissues are described as follows: 

(1) Hyperaemich^tht small blood vessels dilate, with resultant greater 
supply of blood to the part. 

(2) Stasis — as the result of dilatation of the blood vessels the blood^in 
them slows down. 

(3) Exudation of lymph and migration of leucocytes. Owing to the in- 
creased permeation of the minute blood vessel walls, and the slowing 
down of the blood stream, the leucocytes escape through the walls and 
act as phagocytes, scrum exudes through the thin walls and this scrum 
contains fibrin and antitoxin, both of which arc valuable in arresting 
disease — some red cells also escape. 

(4) Proliferation of cells. As the result of the changes described, there is 
proliferation of connective tissue cells, particularly the endothelial and 



INFLAMMATION 559 

fibro-blastic. The endothelial cells form new vessels; the fibro-blastic cells 
result in the formation of fibrous tissue which contracts and forms a scar. 

Symptoms of inflammation. The local signs of inflammation are (i) 
redness^ which corresponds with the hyperacmia, (2) heat^ partly due to 
hyperaemia and partly due to chemical changes going on in the affected 
tissues, (3) swellings which is brought about by the exudation of lymph 
and depends to a great extent upon the looseness of the tissues. For ex- 
ample, in a whitlow, which is an inflammatory condition of the perio- 
steum of the phalange of the finger at the base of the nail, very little 
swelling can take place as the tissues are dense; but in inflammation of the 
orbit, as the tissues round the eye are very loose and almost devoid of fat, 
considerable swelling occurs. (4) Pain occurs as the result of the tension 
in the tissues which exerts pressure on the nerve endings. As the result of 
pain and swelling there is (5) loss of funciion^ which is the natural desire 
of the subject to rest and to avoid using the painful member. 

The termination of inflammation. The result of inflammation 
depends to a great extent on whether the condition was an acute or a 
chronic one. Acute inflammation may terminate in resolution, or there 
may be too much destruction of tissue for this — most chronic inflam- 
matory conditions, however, do not terminate by resolution because the 
tissue changes have been too advanced for this to happen. 

(1) Resolution. The cells which have been destroyed in the neighbour- 
hood of the inflammation by the action of phagocytes, or broken down by 
them, are absorbed by the lymphatics. Some scar tissue remains for a 
time, but it also may be removed by phagocytic action and, when this 
happens and no thickening is left, the tissues are in the same state as 
before the inflammation and are said to have Resolved’. The best example 
of resolution in medicine and surgery is the return to normal of the lung 
after an attack of lobar pneumonia, but resolution can also occur in some 
surgical inflammatory lesions. 

(2) Cell destruction. Because there has been considerable cell destruction, 
certain other changes must take place. The cells may be liquefied and 
broken down and, although a certain amount of this fluid is absorbed, 
more may be formed than can be dealt with and in this case an abscess 
forms. An abscess consists of these liquefied cells and broken-down bacteria 
and pliagocytes. It may work to the surface and burst, but most surgeons 
prefer to incise and drain an abscess. 

(3) Sloughing and gangrene. A slough is usually defined as a small mass 
of dead tissue; the core of a boil is a slough, so also is the mass of grey 
tissue which forms on the surface of an ulcer, or on a very bad trophic 
sore or bedsore. Gangrene is death of a mass of tissue; for example, 
gangrene of a whole limb may occur. 

As the result of death of the tissues, cells are killed but not liquefied, 
and the solid mass results in slough or gangrene. This slough becomes 
separated from living tissue by an area of inflammation which is described 
in the case of a limb as the ‘line of demarcation’; in the case of a slough 
separating from the surface of an ulcer, healthy granulating tissue occurs 
beneath it, absorption of a portion of the slough nearest this tissue w^hich 
becomes liquefied is then possible, and the dead part is cast off. 

Treatment of inflammation. Whenever it is possible the cause of the 
inflammation should be removed. If a child has fallen on his knees and got 



560 INFECTION — INFLAMMATION 

some gravel in, take it out; if a maid has run a splinter in her hand, re- 
move it. The next important point is the application of rest. An inflamed 
hand should be carried in a sling, an inflamed eye should be covered. A 
sprained ankle should not be used. The degree of rest employed will 
depend on the presence of any constitutional symptoms; and since the 
local inflammatory reaction may give rise to a fair degree of malaise 
owing to the absorption of toxins, the patient may be ill enough to remain 
in bed. It is quite usual to find a patient with a b^ septic hand complain- 
ing of headache, loss of appetite, rise of temperature and inability to 
sleep. 

The local treatment depends to a great extent on the cause. If the inflam^ 
mation is non-bacteriaU it is usual to apply cold compresses at the outset in 
order to cause constriction of the blood vessels and so limit the exudation 
of lymph; and in this way the swelling can be limited. If a non-bacterial 
inflammation is not seen until swelling has occurred, heat is employed in 
order to increase the circulation and so promote absorption. 

In inflammation due to bacterial invasion heat is usually indicated, because 
it assists the processes of inflammation to go on and, as already indicated, 
these changes are a normal reaction of the tissues to injury and are there- 
fore a good rather than a bad thing. The application of fomentations, 
hot baths, antiphlogistine, poultices and electric pads will stimulate the 
circulation. Later on, massage is very often considered valuable as it 
assists the return of the lymph to the blood stream, and by this means to 
remove the inflammatory waste products and so assist in repair of the 
tissues. 

In chronic inflammatory conditions counterirritants are sometimes employed. 
These include the application of liniments, iodine and mercury, according 
to the cause of the inflammation. 


HAEMORRHAGE 

Haemorrhage is an ugly word to use to describe bleeding but its use is 
time honoured. Slight bleeding will be arrested by natural means, severe 
bleeding will require treatment to help in its arrest. 

Bleeding may be classified in a number of different ways : 

Causes of bleeding. Local causes include injury which may be acciden- 
tal or intentional — as an operation causes bleeding. Excessive vascularity 
of the membrane lining a canal or cavity may cause bleeding; this is most 
commonly seen in the case of nasal polypi, uterine polypi, and papilloma 
of the bladder. Disease in the vicinity of a blood vessel may cause it to be 
eroded, resulting in escape of blood — this occurs in cancer for example; 
or it may result in sjx>ntaneous rupture of a blood vessel as when cerebral 
haemorrhage occurs. 

General causes of bleeding may include such diseases as arteriosclerosis. 
Purpura is characterized by bleeding into the subcutaneous tissue and into 
cavities and from organs such as when haematuria occurs in purpura. 
Scurvy is fortunately a rare disease today, but it also is characterize by 
bleeding under the periosteum of the long bones, from the bowel and into 
the gums. Some of the varieties of anaemia mentioned on p. 359 are 
characterized by bleeding. Haemophilia is another example of a disease in 
which bleeding is likely to occur. 



561 







563 



184. CiOMPRKSSION OF TUF SoiUJ AVI AN ArI'KRV BY 
I>RFSSIN(i n ACIAINST THF FlRST RiB, BFIIINU IHK ClAVICFE. 

]:>ati(‘iU is lying, llu' operator stands Ixdnnd (see also 
Fig, 185 below). 





,4^5^ 


Idn. 185. Alternative Meitiod 

OF (k)MFRF:SSINO Sl^BCEAVlAN 

Artery. 





ric;. iHb. Compression of the rEMoiEVE 
Artery ey using both Thi mbs and exer i- 
iNCi Si'RONG Pressi:re ON HIE Arteky as 

IT PASSES OVER THE PELVIS. 








r tSflPr 


Fig. 1 87. By Fi.ExiNCi, Abdugtinc; and Rotaitnc; the l iiKin outwards 
THE Femoral Artery can be compressed a(;ainst ttie Head of the 
Femur as it passes over the ERONr of the Hip Ioint'. 



I' Ki. l8B. COM’’RESSl(>N OF THE BrACHIAL Ar l ERY. 

By nu'iuis of a pad at the bend oi' the elbow and tiexion of 
the loreann, i he lingers of the opcTator are seen on the 
radial pulse which is obliterated wlien the application is 
etlec live in compressing the artery. 



Fig. 189. Iwo Pressure Points 
IN I'HE Region of the Anker. 
Of the posterior tibial artery as it 
passes behind the internal malle- 
olus and of the dorsalis pedis as it 
crosses the bend of the atikh*. Tlie 
hand of the operator is shown 
using the thumb to eomj^ress th(' 
dorsalis pedis artery; eount(‘i 
pressure is made by the fingers 
gripping the back of th(‘ heel. 



Fice 190. Pad and 
Flexion applied 
TO THE Popliteal 
Artery behind 
the Knee, to Ar- 
rest R L E E D 1 N G 
FROM Leg and 
Fo(.)r. 





f rF' 


„vi: Hi;*": " 


567 


Fig. 19 1. 

Varieties of 
7 V)urniqeet. 

1. The Tie I cl 
tourniqiuT. 

2. Sainway’s. 

3. li s 1 n a r c h ’ s 
bandage. 

4. Strip of rub- 
ber tubing. 



hui. i()2. Apim.ication of Rubber TouRNiQ^uEr. 
Note th(' ('dort required to stretch the rubber before 
carrying th(' tourniquet round the limb. On the left 
thigh the tourniquet is shown applied. 







HAEMORRHAGE 569 

Type of vessel. Arterial bleeding is bright red in colour; and the blood 
is pumped out with the contxaction of the vessel. This type of bleeding is 
arrested by pressure appHed on the proximal side of the bleeding vessel. 

Verum bleeding occurs as a continuous stream of blood, which is darker 
in colour. It is arrested by pressure on the distal side of the vessel. 

Capillary bleeding is a regular oozing of blood on to the surface, or welling 
up in a wound. It is usually stopped by pressure on the bleeding surface. 

Sites of bleeding. Eplstaxls is bleeding from the nose; it may be due 
to injury such as a blow or from constant picking of the nose; it may be 
due to excessive vascularity of the nasal mucous membrane as when polypi 
are present; it may be the result of small ulcers on the surface of the nasal 
cavity; it occurs in the general diseases which predispose to bleeding: 
purpura, scurvy, some forms of anaemia, high blood pressure, arterio- 
sclerosis and haemophilia. It may be a symptom of onset of one of the 
infectious diseases or of influenza. 

The treatment of epistaxis is to sit the patient up and hold a basin to catch 
the blood; cold should be applied over the bridge of the nose and over the 
upper lip — whence some of the blood vessels supplying the nose pass to it. 
The patient may gently rinse his mouth with water, and have ice to suck. 

The nose should be pinched, as pressure applied to the fix)nt part will 
stop the bleeding there. If the bleeding continues it may be necessary to 
pack the nose with gauze soaked in adrenalin. If post-nasal plugs arc 
needed these should be inserted by a surgeon. 

The patient should be kept quiet, and when there is danger of recurrence 
of bleeding he should have a light diet, given cool not hot, and stimulants 
should be omitted for a few days. 

In some cases, when considerable loss of blood has occurred and the 
patient is suffering from shock, he may not be able to be propped sitting 
up and he should then lie down; in this instance epistaxis is complicated 
by shock and both factors require treatment. When shock is severe, saline 
infusion and blood transfusion may be necessary. 

Haemoptysis is bleeding from the lungs; the blood is coughed up, and 
as it is mixed with air it consequently often looks frothy, but it may also 
be mixed with sputum; it is usually bright red in colour. Haemoptysis 
occurs most often in pulmonary tuberculosis, but it may also complicate 
initral disease of the heart, and aortic aneurysm. The treatment is described 
in detail on p. 376. 

Haematemesis is vomiting of blood. As a rule it comes from the 
stomach, but it may have first been swallowed as might happen in severe 
epistaxis, and it naay also have regurgitated into the stomach when severe 
bleeding complicates duodenal ulcer. 

Vomited blood, which has been some little time in the stomach, is 
mixed with gastric juice or maybe with food; it is of a characteristic colour 
and coimstence— -like coffee grounds — and is > acid in reaction. The 
treatment is described on pp. 381-2 in which an example is given of a 
patient with a very severe haematemesis who is admitted to a medical 
ward. 

Haematuria is blood in the urine; when a small amount is present the 
urine will be slightly smoky in appearance, and this renders it less clear 
than normal. When a lot df blood is passed the urine may be bright red 



570 INFECTION— nWLAMMATION 

and clots may be present. When the blood is well mixed with the tirine 
it is usually ^e kidneys^ when passed at the end of the act of mic* 
turition it is probably fixun the bladder; and, if passed at the beginning 
of the act, it usually indicates that the urethra is bleeding. 

Malaena is the presence of altered blood in the stool; it may be present 
in large quantities, rendering the stool dark like tar, or there may be only 
a trace. 

Uterine bleeding. Severe uterine bleeding may occur in disease of the 
uterus, particularly if polypoid growths arc present, when the cavity is 
enlarged by the existence of fibroids, and in carcinoma. Such a condition 
calls for immediate treatment, and if a nurse has to deal with it she should 
elevate the foot of the bed, give a hot vaginal douche, prepare articles for 
packing the vagina and also for the administration of an intra-utmne 
douche. The surgeon will give this, but the nurse must be prepared to pack 
the vagina. Ergot, |-i drachm may be administered pending the arrival 
of a surgeon, if bleeding is severe; or, alternatively, a preparation of ergot 
may be given. 

Extravasation of blood is the term used to describe the condition 
when blood is poured into the subcutaneous tissues; the area becomes 
swollen, and often tense and brawny. A large localized collection of blood 
is described as a Aamatoma— this may, however, become absorbed in time; 
if not, aspiration of the tumour of blood is usually tried; but when com- 
plicated by sepsis it is incised and drained. A small collection of blood 
immediately beneath the skin may be petechial in character, just minute 
puncta of blood. A larger collection in the same situation is a bruise or 
ecchymosis, 

A large amount of blood may be present, and the aim of treatment is to 
prevent further effusion — ^rest and the application of cold may help in this. 
Later, the aim is to help absorption and removal by lymphatic and blood 
vessels, and applications of heat and gentle massage around the bruised 
area will assist in this process. A black eye is a good example of a severe 
bruise. 

The time at which bleeding occurs. Primary bleeding occurs at tlic 
tim e of injury; reactionary or interrrudiate bleeding occurs within 24 hours of 
it. This is due to the rise of blood pressure which occurs as a patient re- 
covers; he may return to consciousness, and cough or vomit and just this 
slight movement may be enough to start bleeding. Reactionary bleeding 
may also be due to the injudicious use of stimulants, to a clot being forced 
out of a vessel or to the sUpping of a ligature — ^but this is rare. 

Secondary bleeding does not usually occur until a week or ro days have 
elapsed; though the term is used to describe any bleeding which occurs 
after the first 24 hours after injury. It is practically always due to infection; 
the wall of the vessel is gradually weakened by this and finally gives way, 
resulting in .bleeding. 

Bleeding is also classified, or more correctly described as being either 
external when it can be seen, as for example in cut throat; or interned or 
concealed when the symptoms of profound shock and anaemia suggest 
that the patient is bleeding internally. 

The symptoms associated with bleeding should be well known and 
quickly recognized. The skin is ccid, pale and clammy, the temperature 



HASlIORRItAOB 57 1 

being so low that the moikuce is not evaporated fk>m its surface, as it 
should be. The extremitiw of the fingers and toes, and the ears and lips 
are livid; the eyes are deeply sunken in their sockets and the pupils may be 
dilated; the face looks pinched; the patient gasps in breathing, as he is 
suffaing from air hunger owing to the diminution of the haemoglobin 
content of his blood by reason of the loss of red cells in the blood which he 
is losing; his breathing is rapid and sighing. Owing to lowering of the 
volume of fluid in the blood vessels, the pulse is rapid, weak and irregular; 
the blood pressure is low. 

The patient will complain of thirst, of feeling suffocated, and he will 
move about restlessly in his effort to obtain the air he feels he needs. If he 
attempts to sit up he vrill feel faint and may faint; he may also complain 
of buzzing noises in his head and dizziness. 

When bleeding is very severe syncope may be immediate and fatal; 
when less severe there may be attacks of syncope, and between the attacks 
weakness and collapse will be very marked. 

The provision made by nature to arrest bleeding consists of ( i ) decrease 
of blood pressure due to loss of blood and lowering of the activity of the 
nervous system — the heart will beat less forcibly and the blood fluid collects 
in the small vessels in the abdominal cavity. 

(2) The clotting of blood. As mentioned on p. 577, bloodclot forms more 
readily in a tom or lacerated vessel than in one which is cleanly incised. 
The decrease of blood pressure prevents dislodgement of the clot from the 
open mouth of the cut vessel. 

(3) Retraction and contraction of the walls of the divided arteries. A cut vessel 
shrinks slighdy in size by contraction of the muscular and elastic tissue 
in its walls; in addition the middle coat — the intima — retracts, or curls in, 
and so helps to retain the clot in the vessel against the pressure of the blood 
behind it. 

Mechanical measures which may be used in the arrest of 
bleeding are applied locally. These are applications of heat and cold. 
Examples of heat are the hot vaginal douche recommended for uterine 
bleeding; applications of hot wet towels employed in the treatment of 
bleeding during operations on the abdominal cavity. Examples of cold 
include the cold compress applied to the nose and lip in the arrest of 
bleeding in cpistaxis, ice applied to the head for cerebral haemorrhage, 
and the natural tendency to put a cut hand beneath the cold water tap. 

The use of styptics. The application of adrenalin in surgery of the ear, nose 
and throat for example; other styptic agents commonly employed are 
tannic add, perchloride of iron, peroxide of hydrogen and nitrate of 
silver in a weak solution. 

By elevation of the bleeding part, which makes the blood flow upwards, 
against gravity, the loss may be slightly lessened pending the preparation 
of more useful measures. 

The application of pressure, proximal to the bleeding point in arterial, 
and on die spot in venous, bleeding. Every nurse should be familiar with 
the main pressure points of haemorrhage; she never knows when she will 
want to apply this knowledge; moreover, a merely theoretical knowledge 
wiU not help her; she must practise applying pressure over these arterial 
pressure points either on herself or on her friends, and she can test her 
efficiency by trying to find the puke bdow the pressure point — ^which 



572 INFECTION — INFI-AMMATION 

should be obliterated, if her pressure is oti the right spot. The principal 
pressure points and methods of applying digital pressure are shown in 
%s. i8i to 191, pp. 561 to 566. 

Pressure may also be applied by means of a tourniquet. Plugging a wound 
or other cavity from which bleiKling is taking place and firmly bandaging a 
dressing on may also be tried in certain situations. 

The application of ligatures to bleeding vessels, once the points have been 
secured by means of artery forceps, is not usually within the province erf" a 
nurse. 

The general treatment of a patient who is bleeding is as follows — He 
must stay in bed and be kept quiet and warm; his head should be low, as 
he so easily feels faint. He should be confidently reassured in order to get 
his mind at rest; morphia will be ordered as a rule and the nurse should 
prepare this as soon as possible, so that when the doctor comes, who can 
order it, it is ready to give and even a moment’s delay is avoided. In no 
circumstances should any stimulant be given, but thirst should be ailiayed 
by drinks of water, or half-strength saline may be given. The replacement 
of the lost fluid is very important, and as the patient is thirsty he will be 
ready to drink and should be given as much as he will take. If he will take 
enough fluid by mouth other means need not be employed, but otherwise 
it may be given rectally, subcutaneously and by the intravenous route 
(see p. 196). 

The replacement of blood. So much of the patient’s discomfort and many 
of the symptoms present are due to the diminished supply of oxygen to the 
vital organs of his body, owing to the loss of red blood cells and consequent 
loss of the oxygen-carrying haemoglobin, therefore blood transfusion may 
be given. 

ULCERS 

Gangrene has already been described as massive death of tissue — 
ulceration may be described as molecular death of tissue, cell by cell. An 
ulcer is a sore on the surface, and it may be on the outside or inside of an 
organ as in the case of peptic ulcers (see p. 379). Ulcers arc classified to 
some extent according to their cause, such as traumatic, pyogenic or 
trophic; q)ecific when due to syphilis or tuberculosis and malignant when 
due to cancer. They are also classified according to their position, or some 
characteristic such as a varicose ulcer, gastric or duodenal ulcer, corneal 
ulcer, rodent ulcer. 

When a nurse is called upon to apply treatment to an ulcer, she should 
have some idea of the state the ulcer is in at the outset, and should be able 
to describe whether its condition remains stationary, whether she thinks 
healing is taking place, or whether the ulcer is spreading. 

An ulcer consists (rf a bed which is the floor or surfiice of the ulcer, of 
edges which form the margins of the ulcer, and it usually is covered by an 
exudate or discharge. A healing ulcer is free from discharge, it has a pink, 
regular granulating floor, and shelving edges, and the epidermis can be 
seen gradually encroaching on the surface o£ the ulcer. A healing ulcer is 
movable on the structures beneath it and its margins are quite free from 
any area of inflammation. In the treatment of such an ulcer, protection 
is required by means of a sterile dressing, and it should be kept very clean, 
and the sur&ce free from any excessive granulations. 



VLOERS 573 

stiUioneay tdcer is frequently described as atonic or indolent. Its floor 
is covered by pale, irregular granulations, and iti edges are usually hard 
and bound down to the structures beneath them. Such an ulcer requires 
stimulating. Zinc is one example of a stimulating and healit^ dressing; 
a more recent form of treatment of callous indolent ulcers is by the 
application of elastoplast, which is a thick adhesive plaster containing 
certain antiseptic properties; by means of its elasticity it helps to improve 
the circulation of the part to which it is applied. 

\ spreading ulcer is usually covered by unhealthy granulations or a 
slough, and is surrounded by a zone of inflammation by which it spreads 
to the surrounding parts. In the treatment of this ulcer any discharge or 
exudate from it should be removed by applications of fomentations and 
then, when it has been cleaned, it should be treated by stimulating 
applications as in the case of an indolent ulcer. 


TUMOURS AND CYSTS 

A tumour is a swelling; a neoplasm is a new growth in the tissues. A cyst is a 
sac of fluid, and the term is used to describe a cystic swelling — a sebaceous 
cyst for example, which is a little swelling produced by blockage of the duct 
of one of the sebaceous glands in the skin or scalp, and in this case the fluid 
contained in the sac is sebum. 

A dermoid cyst is an abnormal development of structures pertaining to 
the skin. It consists of a sac, containing skin, hair and teeth, which is 
usually congenital in origin. 

Tumours. The application of this term is confined to description of the 
solid swellings consisting of new growths of cells. It may be simple (be- 
nign) or malignant, and the differences in the structure, mode of growth 
and dangers of these two classes are outlined below: 


Simple Tumour 

Composed of cells similar to the 
tissue in which it grows. The 
cells are therefore haimless. 

Encapsulated, and so the growth 
is confined. 

Of comparatively slow growth. 

Usually painless, but may cause 
pain by pressure on nerves in 
Its vicinity. 

Dangers. Pain, as above and in- 
convenience due to position or 
size. 


Malignant Tumour 

Composed of cells unlike those of 
the tissue in which it is found. 
These cells are destructive. 

Has no capsule, but spreads into 
the surrounding tissue. 

Grows fairly rapidly. 

Painless at first, but by the time 
pain is experienced much dam- 
age has been caused. 

Dangerous to life. Spreading locally 
by infiltration and also by the 
lymphatics and blood, with the 
result that secondary deposits 
occur in other organs. Locally, 
ulceration occurs, followed by 
blockage of the lymphatics and 
consequent oedema. 


Ghissificatioii of Tumours. In addition to being classified as either 
simple or malignant, simple tumours are described according to the type 
of tissue in which ffiey occur. Tumours of epithelial tissue are described as 



574 INFECTION — ^INFLAMMATION 

ipit^Umata, when on the surface of the skinf as p^iUimuUa, when _ 
jecting &om the surface or into a cavity; and as adenomata when pr^ent 
in the tissue of a g^nd. 

Connective tissue tumours when present' m &t and composed of it are 
lipoma', of fibrous tissue, of nerve tissue, glioma', of muscle, myoma', 

of bone, osteoma; of cartilage, chondroma. 

The treatment of a simple tumour may be necessary because of the 
inconvenience it causes; for example, a small lipoma on the face will be 
removed because it is disfiguring; a large myoma may be causing pain by 
pressing on the nerves in its vicinity, and this would indicate that it should 
be removed. Any tumour in the breast should be removed, because the 
breast is one of the commonest sites of cancer and the irritation caused by 
the presence of a simple tumour might cause malignant changes to occur 
in the tissues, though it is not usual for a simple tumour to change its 
nature in this way. 

A malignant tumour may be either carcinoma or sarcoma. Speaking 
very generally, carcinoma affects epithelial tissue and will therrfore be 
most commonly found on the skin and mucous surfaces, and in the cavities 
of the organs of the body and also in the substance of the organs when 
these consist of ducts, tubules and glands and are therefore lined by 
endothelial tissue. 

When the growth or tumour is present on the surface the term epithelioma 
is used to describe it; when in the substance of a gland it is known as 
carcinoma. Carcinoma is of different types according to the character of the 
cell of which the growth is formed; the more virulent types will have a 
graver prognosis than those of lower virulence; but it is not necessauy for 
the nurse to be familiar with this mode of classification. 

Carcinoma spreads by ir^tration — that is, directly into the tissues; it is not 
confined by any surrounding capsule and its growth is consequently 
irregular and rapid; the area of tissue into which this growth extends is 
described as the cancer area. It is for this reason and in order to ensure the 
greatest possible success that a surgeon when removing a cancerous 
growth also removes a very large area of the surrounding structures. 

Sarcoma is the term used to describe cancer when it affects the con- 
nective tissues of the body, such as bone, cartilage and muscle — though 
this use of the word is not invariable. 

Sarcoma spreads by means of the blood stream; unlike carcinoma, 
which derives its nourishment from the surrounding tissues, sarcoma is 
very richly supplied with blood, by the formation of new blood vessels 
within the growth. It is because of this that secondary deposits so rapidly 
occur in sarcoma. The venous blood returning to the lungs to be purified, 
and carrying its load of disease, frequently results in secondary growths 
in the lungs; similarly the blood from the alimentary tract, being carried 
by the portal system to the liver, will give rise to secondary growths in 
this organ in cases of cancer of the stomach or intestine. 

The treatment of cancer is either its earliest possible destruction by 
applications of radium, or removal of the growth by surgery. The nursing 
of cases of cancer is dealt with in chapter 50. 

{In order to avoid repetition other causes of deformity have been dealt with in the 
chapter on ortiwpaedic nursing, see p. yjp.) 



Chapter 38 

Injuries to Soft Structures 

Burns and scalds — Wounds, contusions and bruises — Crush y>ndroine — The 
healing of wounds — Care of an infected wound — Injuries to tendon, muscle and 
nerve — Stings and bites — Foreign bodies in the tissues 

BURNS AND SCALDS 

Burn is due to the action of dry heat as contact with fire, flame 
AA or hot air; and a scald is due to moist heat, such as contact with 
X JL. steam, boiling water or other hot fluids. Bums produced by cor- 
rosive acids and alkalis, electricity, X rays, radium and ultra-violet light, 
arc very similar as regards the destmction of the tissues but they are much 
slower in healing than the burns and scalds produced by heat. Burns 
produced by nitric acid tend to go on burning and penetrate deeper into 
the tissues and produce a more serious degree of injury than the amount 
of acid used would suggest at the outset. 

The injuries produced by burns are divided into five or six degrees. The 
fint two are erythema, or reddening of the skin, and vesication, or blistering. 
In the third degree the superficial layers of the skin are destroyed and the nerve 
endings are exposed. This is the most painful type of burn. In the fourth 
degree there is destruction of the whole thickruss of the skin. The nerve endings 
are destroyed, but it is less painful than a burn of the third degree. In the 
fifth degree the tissues beneath the skin, including the muscles, are adso 
destroyed, and in the last d<^ee there is extensive charring, including 
that of bone. 

Symptoms, dangers and complications. It is very important for a 
nurse to realize that when a patient is badly burnt the great immediate danger 
is shock, which is most severe in the more painful degrees; the severity of 
shock is also contributed to by the extent of the area affected, as destruc- 
tion of the skin permits evaporation of the fluid from the soft tissues. 

About ia-34 hours after the initial injury, in the case of a severe bum, 
the patient will become very prostrated, and this is described by some 
authorities as a stage of secondary shock. It is probably also contributed to 
by the liquefaction of the broken-down proteins and their absorption, 
giving rise to a certain degree of toxaemia, accompanied by fairly marked 
dehydration. At this stage the patient becomes increasingly restless, he suffers 
from thirst, his blood pressure is low, and his colour of an ashen grey tint. 
These symptoms are largely due to loss of fluid from the vascular system. 

As the days progress, the danger of infection is present, pardy due to the 
lowered resistance of the tissues, and to the conupg in contact with dirt 
of a raw surface, which gives rise to more marked signs of toxaemia, and 
the patient may develop septicaemia. As a result of local sepsis, pockets of 
pus may be found under crusts of dead material. 

The darker of deformity which results from severe scauring in the later 
stages of the illness must also be considered. As a result of destruction 
of me superficial tissues a good deal of contrau:tion takes place as healii^ 
pre^prenes and, unless care is taken to see that deformities cannot occur, 

575 



57® INJURIES TO SOFT STRUCTURES 

this contraction, by drawdng the parts together, will give rise to very 
disabling deformities. 

Treatment. As regards treatment, burns are considered in two group>s : 
those where the skin is partially destroyed, as in the first and second degree 
burns, and those where the ^n is completely destroyed. In the treatment, 
prevention of shock, toxaemia and sepsis are of first importance. The 
actual treatment can be considered under first aid, hospital treatment 
and after care. 

First-aid treatment. Morphia in liberal doses to relieve pain and fluids 
and warmth to relieve shock are the first considerations. Any local 
applications must be quickly made. Warm compresses of Milton made by 
using equal parts of Milton and warm water, sodium bicarbonate, two 
teaspoonfuls dissolved in a pint of water, saline, prepared by dissolving 
one teaspoonful of salt in a pint of warm water, or even water can be 
applied to exposed surfaces and also over burnt clothing. Glentian-violet 
jelly can be smeared on exposed parts such as the face, neck and hands. 
It forms a protection and lessens pain. 

Hospital treatment. Shock must be treated first. Warm coverings, an 
electric cradle, elevation of the foot of the bed, morphia, hot ^nks, 
warm fluids by rectum, inhalations of oxygen and intravenous infusion 
of plasma (see p. 198) may all be employed in relieving shock. Local 
treatments include coagulants, antiseptics, baths and packs. 

Tamic acid solution may be employed alone or combined with anti- 
septics. After a preliminary cleansing of the burnt areas it is sprayed on 
until a firm coagulant is formed. By this means loss of tissue fluid is pre- 
vented, and pain is relieved. 

Gentian-violet is an alternative coagulant which is thought to have fewer 
disadvantages. It may be used alone or combined with other coagulants — 
tannic acid or silver nitrate. 

When coagulants are employed it is important to sec that oedema does 
not occur beneath the coagulum causing pressure on tendons and joints, 
and interfering with the circulation as this may result in necrosis and 
limitation of movement. 

Antiseptics. A mixture of acriflavine, brilliant green and gentian violet 
{triple dye) may be painted on or applied as compresses. These anti- 
septics arc non-irritatii^ and cause slight coagulation. 

Saliru baths or packs. Immersion of the affected parts or of the whole body 
in warm saline twice a day is a method advocated by some authorities. 
Between treatments the burnt areas arc covered with tulle gras over 
which saline packs or compresses may be applied. These can then be 
floated off the areas during the next bath, and in this way painful changing 
of dressings is avoided. 

Tulle gras is prepared by taking curtain net with a mesh of 2 mm. and 
cutting it into suitable sizes. These pieces arc placed in a tin and covered 
with paraffin 98 per cent., balsam of Peru i p>er cent, and halibut-liver oil 
I per cent. The contents of the tin are sterilized and the layers of tulle 
gras used as required. 

The protective Envelope method of treatment is recommended by John 
Bunyan, who has introduced intermittent irrigation by weak solutions of 
electrolytic sodium hypochlorite {Milton). 

A preliminary deansing of the burst area is effected by hoang down with 



BURNS AND SCALDS 577 

a 10 per cent, or 30 per cent, soludon. The affected parts arc then encased 
in Stannard’s silk-coated envelopes. These may be sterilized by boiling, by 
steam disinfecdng at 320® F. or by soajdng in a 10 per cent, soludon of 
Milton for 20 minutes. No other dressing is needed. The envelope gives 
protection, permits movement to be carried out, maintains the covered 
areas at normal body temperature and excludes the air, so preventing 
infection and acts as enclosure of the field for irrigation. Envelopes are 
made to fit any part of the body, head, limbs and trunk, or the patient 
may be enveloped entirely in an envelope bath. No clothing is worn 
beneath the envelope. Treatment is performed for three daily periods of 
30 minutes each, a reservoir of fluid of an exact temperature of 100° F. is 
suspended above the bed, the solution is allowed to flow into the envelope, 
over the burnt areas and drains from the envelope by an exit channel 
provided. After irrigation the envelope must be thoroughly well drained 
of fluid otherwise maceration of the parts would occur. 

Phosphorus bums may be severe and are difficult to heal. The first-aid 
treatment is therefore most important and consists in plunging the affected 
parts into warm water in which washing soda is dissolved (two table- 
spoonfuls to the pint, or half a pound to the gallon), or if this is not avail- 
able, warm or even cold water may be used; alternatively the affected area 
may be covered with very wet compresses. 

By excluding air the burning phosphorus is extinguished and the pro- 
ducts which destroy the skin are neutralized. Any bit of phosphorus 
adherent to the skin may be sponged off or picked off with forcejM. The 
first-aider must avoid contaminating his hands. The area can be dressed with a 
solution of copper sulphate, one teaspoonful to the pint. Oils and oint- 
ments must be avoided as these dissolve phosphorus and will spread 
contamination. Clothing, furniture, &c., splashed with phosphorus must 
be kept wet until the phosphorus has been removed. 


WOUNDS, CONTUSIONS AND BRUISES 

Wounds are injuries to the tissues of the body, and they are commonly 
classified according to the type of wound inflicted — such as an incised 
wound which is a clean cut, made usually by some sharp cutting instru- 
ment. Bleeding occurs freely. 

A contused wound is bruised — that is, the tissues are crushed beneath the 
skin which may not be broken; blood exudes into the subcutaneous tissue 
as in a bruise. 

In a lacerated wound the structures are torn and the edges frayed and 
jagged. Tearing of the tissues exerts torsion on the injured blood vessels 
and consequently the bleeding is very slight in such a wound. The danger 
of a lacerated wound is sloughing and gangrene, as the edges may be deprived 
of blood, by crushing; sloughing if extensive will result in septic infection 
of the wound. 

A punctured wourd is usually made by stabbing with a sharp instrument; 
as a rule it is a deep wound, and the injury to deep structures may be very 
grave. Dirt and particles of clothing may be carried into the woimd with the 
instrument used, resulting in the grave danger of deep seated septic infection . 

Penetrating wounds of the walls of the cavities of the body are 
luually of the dass described as punctured, and the organs contained in 



_ 57 ® INJURIES TO SOFT STRUOTURES 

these cavities may be so seriously injured in this type of wound that danger 
of death is imminent. In a stab wound of the chest, the lung is most usu^y 
injured; this may give rise to serious bleeding, or to collapse of the lung, 
wMch is characterized by serious embarrassment of the breathing, 
accompanied by heart fiulure and surgical emphysema. In emphysema 
air itom the punctured lung enters the subcutaneous tissues; this may be 
local at first, but in a serious injury there is a danger of generalued 
emphysema which, combined with shock and pulmonary embarrassmont, 
may rapidly prove fatal. 

In penetrating wounds of the abdomen die liver, kidneys, spleen, stomach, 
intestine, or bladder may be injured, and in this case there will be con> 
siderable internal bleeding, accompanied by shock. Unless the bleeding 
is continuous the patient usually recovers firom shock fairly rapidly; but 
if he does not respond to rest, and treatment for shock, it may be con- 
cluded that the bleeding is continuous; he will then get worse, become 
very pale and restless, complain of thirst, suffer from shallow sighing 
respirations and have a rapid running pulse of low volume. 

When one of the hollow organs is perforated, the symptoms of this will 
be characterized by marked collapse accompanied by boardlike rigidity 
of the abdominal wall. 

Either of the two conditions described above is considered to be an acute 
abdominal catastrophe which calls for early surgical treatment (see p. 654) . 

If file early symptoms arising after a penetrating wound of the abdomen 
are not as severe as those mentioned in the two instances given above, the 
wound will usually be cleaned as well as possible, either with the aid of a 
general anaesthetic or not, and the patient will be kept under careful obser- 
vation in case peritonitis should occur later, which is the danger to be feared. 

Bleeding is another complication to be feared from a deep flesh wound, or a 
wound in a cavity. When this happens, it will be necessary for the condition 
to be surgically investigated; if bleeding vessels are discovered, these will 
be ligatured. The wound will be packed, and as a rule this pack will be 
retained for from 24 to 48 hours. When it is to be removed it will first be 
saturated (preferably with some antiseptic agent which is also hae- 
mostatic, such as peroxide of hydrogen), in order to avoid injury to the 
walls of the cavity as the gauze is withdrawn. Another packing should 
be ready at hand in case bleeding occurs, and it is considered desirable 
to repack the wound. 

The general treatment of a patient who is bleeding is the provision of 
absolute rest, the administration of morphia, and the judicious treatment 
of the shock which is invariably present; with, as far as possible, an 
avoidance of any stimulation of the circulation, which, by raising the 
blood pressure, would predispose to further bleeding. (See also p. 635). 

Scalp wounds bleed a great deal; they are usually clean, incised 
wounds. In the treatment of wounds of the scalp, the hair around the injury 
should be cut away and the scalp carefully shaved; frequent mopping 
will have to be employed because of the bleeding. The surgeon will then 
inspect the injury and, if he decides to suture it, will clean the wound with 
antiseptics, get the edges into apposition, and put in the necessary sutures; 
otherwise he may retain the edges in apposition by the application of 
strapping or strip of elastoplast. The wound is usuaUy cove^ by a pad, 
firmly t^ndaged on. 



WOUNBS, CONTUSIONS AND BRUISES 579 

la subsequent caiu of-sucii a case it is very necessary to arrange for 
^e patient to have rest; if the patient remains in hospit^ he will he 
in bed. Every probationer nurse should make herself familiar with the 
symptoms and signs of cerebral concussion and compression very early in 
her training; in this instance for exam|:de it is imperative to be on the watch 
for symptoms of these two conditions, which should be recognized and 
reported upon without delay. (See also care of a case of fracture of the 
skull on p. 598.) 

Wounds of the face. These arc usually superficial wounds which bleed 
readily; the facial structures are very mobile and the face is a difficult 
part on which to retain a dressing. 

A wound of the face requires similar treatment to one of the scalp. A 
type of dressing often applied to the face is collodion which serves two 
purposes — it obviates the necessity of a bandage and it can be applied 
under slight tension, thus preventing movement of the margins of the 
wound with every movement of the skin of the face. 

To apply a collodion dressing to the face it is absolutely essential for the part 
to be dry, as neither collodion nor Whitehead’s varnish will adhere 
properly to a damp surface. The blood should first be cleaned away; pre- 
suming sutures are not being used, but that some slight tension is to be 
maintained by means of the collodion, the edges of the wound should be 
brought into apposition, the area blanched by grasping it firmly between 
thumb and fingers, the blood wiped away until the edges of the wound are 
quite dry, and the collodion then painted on, the parts being held together 
until it sets, when it may be gently released and a second layer of collodion 
applied. A filmy layer of sterile cotton wool, or a single thickness of gauze 
laid over the wound first, over which the collodion is applied, will make 
a slightly firmer dressing. 

A wound of the lip bleeds very freely and usually requires stitching, 
the dressing should be applied under as much tension as can be obtained, 
as the lip is so freely mobile. 

A wound of the nose will bleed very freely and serious epistaxis may 
result from it (for treatment see epistaxis, p. 569). 

A wound of the ear is aways serious as the drum may be ruptured, 
and if this occurs the injury may have been sufficiently serious to be com- 
plicated by fracture of the base of the skull. 

Whenever a nurse is in charge of a patient who has had an injury 
to the ear, it is essential to keep him at rest, in bed if possible. The car 
should be carefully swabbed out, using sterile swabs, aural forceps and 
weak peroxide solution or boracic lotion. A small piece of sterile wool 
should be kept in the meatus and whenever this is removed it should be 
carefully inspected to see whether the discharge on it is blood, serum or a 
watery fluid — if the latter is seen, it may be that cerebrospinal fluid is 
escaping owing to penetration of the dura mater, which is a very serious 
injury. The general condition of the patient should be observed, his pube 
rate noted frequently and any" signs of concussion or compression or cere- 
bral irritation (sec p. 600) reported at once. 

Cut throat is an emergency with which a nurse may have to deal until 
the arrival of a doctor, and it is usually an attempt at suicide. When the 
gash is at the front of ffic neck — ^which is usual — the trachea has received 
most of the injury. The degree of injury must be the guide for treatment; 



580 INJURIES TO SOFT STRUCTURES 

when only the skin and superficial tissues are cut, these will bleed finely 
and the patient will prol^bly be very fiightened. If he is put to lie down 
and his head is pressed towards his chest, this position will cause pressure 
on the bleeding parts and so prevent some of the bleeding. If, however, 
the trachea is severed it is imperative (i) to maintain an airway, or 
asphyxia will occur, and (2) to prevent blood fiT>m getting into the 
trachea as this will result in inhalation pneumonia later. 

A doctor should be summoned, the patient may not be left, the instru- 
ment he has used should be removed, out of his sight, and he should be 
covered and kept warm. 

The dangers of cut throat are those already mentioned, bleeding, asphyxia, 
shock and, later, inhalation pneumonia, or pneumonia may arise as the 
result of exposure, and sepsis may abo occur. 

When the doctor arrives, if the wound is only superficial he will clean 
it, put in sutures if necessary, and apply a dressing. When the trachea has 
been incised a tracheotomy tube is inserted. For nursing care of tracheo- 
tomy see p. 730. 

Crush syndrome is the term used to indicate the characteristic features 
of a condition arising as the result of the pinning down of a limb by some 
heavy object for some hours after the collapse of a building in air raids. 
When rescued, the patient may seem quite well, but some hours later he 
suffers severely from shock, followed by haematuria and suppression of 
urine. 

There are two schools of thought regarding the probable cause and treat- 
ment of this condition, (i) The cause is thought to be due to toxins by 
damaged muscle entering the circulation and causing nephritis. This 
school suggest as treatment: (a) amputation .of the limb, and/or (b) giving 
intravenous infusion of blood, serum, or saline in an attempt to prevent 
the fall in circulating fluid. (2) The second school consider the condition 
of shock and reduced renal output to be due to release of the blood 
constituents into a limb which had been compressed, and in which the 
arterial circulation had for a time stopped; when the pressure on the limb 
is released, the blood rushes into the limb with consequent fall in the 
circulating blood volume and resulting shock followed later by decrease 
in renal output. This school consider that by bandaging the limb tightly, 
oedema with its attendant symptoms can be prevented and alternatively, 
that intermittent pressure apphed by some form of mechanical apparatus 
may also help. 

THE HEALING OF WOUNDS 

Most wounds heal by what is commonly described as first intention. 
A clean cut, or incised wound, made on the operating table, is expected 
to heal in this way, and for this it is essential that the wound edges should 
be accurately approximated without imdue tension. The cut edges bleed 
slightly, and the space between them becomes filled with blood and 
lymph and injured tissue cells. It is then invaded by leucocytes which 
ingest all this foreign matter. Little capillary blood vessels are given off 
from the blood vessels on each side and infiltrate the debris in the wound, 
and so bridge the gap and restore the circulation. 

In the care of this type of wound, it is necessary to keep the surface dry 
by means of a sterile dressing, and to keep the part at rest imtil the edgt» 



THE HEALING OE WOUNDS 58 1 

Imve unhed. The approximated edges will be held together by clips or 
stitches. Michel’s dips are usually removed before the ^h day by means 
of special fcmxps, and other skin sutures are takdi out by the tenth day. 
In observing the condition of the wound edges as healing progresses, the 
nurse must always be on the look out for any irritation caused by the 
stitches. The edges of the skin around the stitches would be red if friction 
were permitted, and this might occur if a dressing were too loosely 
bandaged on. Mild infection of a stitch puncture might result in a small 
stitch abscess. In this case the first thing to do is to attempt, by keeping 
the area dry with powder such as aristol, to prevent the spread of infection 
to other stitches. If this is not possible, and the infection is more than very 
slight, it will be necessary to remove the offending stitch and to apply a 
moist dressing. A spirit dressing is very effective. When the infection is 
more marked, and invades several stitches, it may be necessary to treat the 
inflammatory area by hot applications. 

In some instances the protection of stitches by collodion or Whitehead’s 
varnish is employed; as for example in operations on the face where it is 
neither convenient nor practicable to apply either strapping or bandage. 

Healing by second intention. This is the way in which an open, 
gaping wound heals — blood, lymph and injured tissue cells fill the cavity, 
and tiny little capillary loops of blood vessels are formed all over the area 
of the wound. These are very red in colour, easily injured and bleed when 
touched. 

At this stage such a wound requires a protective dressing of a nature 
that does not dry, and so injure the tissues whenever the dressing is 
changed. In time a little fibrous tissue forms, and this strengthens the 
newly formed capillary buds, and also causes contraction of tissue, so that 
the wound becomes gradually smaller as the cavity becomes filled by 
granulated tissue and the surface of the wound is eventually covered by 
scar tissue. 

Throughout this healing process the nurse will dress the wound daily, 
or oftener if necessary, and she must be able to decide whether it is healing 
or not. A healing granulating surface will be velvety in appearance and 
pink in colour. A duggish wound might be pale and shiny in character, 
and this would require a stimulating dressing such as hypertonic saline 
compresses, one of the aniline dyes, or red lotion, containing zinc — a very 
healu^ substance. On the other hand excessive granulations, commonly 
called ‘proud flesh’, may cover the surface of the wound. This is an 
unhealthy growth and must be destroyed before healing can proceed. It is 
usttal to apply cither silver nitrate, or copper sulphate — ‘blue stone’ — 
for this purpose. In both instances the whole surface of the excessive 
granulation is smeared with the caustic substance. As the surface of the 
wound is moist there is no necessity to wet the caustic. 

In the subsequent dressing of this wound, a moist, not a dry, dressing 
should be employed, and it should be changed after 6 hours because the 
ciction of the caustic in destroying the granulating area will give rise to 
sloughing. If a dry dressing is applied, the sloughing area beneath, covered 
by a pool of exudate, will be confined beneath the dressing as if corked 
up; but the application of a moist dressing will permit the exudate, formed 
by the destruction of die excessive granulations, to be absorbed by the 
dressing applied. The reason for changing the dicing within 6 hours is 



58 a INJURtfiS TO SOTT BT&tlOTtmES 

that the exudate may be removed and not kept in contact with the wound 
any longer than necessary. 

Secon£ay suture is the pasnng of sutures through deep structures in order 
to take the strain off the skin sutures. A secondary suture is also described 
as a tension suture. 

CARE OF AN INFECTED WOUND 
(See eleo Gee Gengrene p« 557) 

When a wound is infected the surfaces are red and swollen and a dis- 
chat^e of pus is present; the surrounding parts are tender and painful. 
Most accidental wotmds are liable to become infected, as they may be 
contaminated by road dirt, and particles of clothing. 

The aim in the care of all wounds is the prevention of infection. To this 
end certain points should be attended to at the outset, including; 

(a) The removal of all foreign particles; 

(b) Thorough cleansing of Ae cavity and the margins and edges of 
the wound, with the removal of any tom parts, which have probably 
been deprived of blood supply and will therefore slough; 

(c) The proAUsion of adequate free drainage of serum or other dis- 
charge from the wound; for adequate drainage the openings provided 
must be lai^ enough to permit escape of discharge from the whole of the 
cavity of the wound; 

(d) The affected part should be kept free from movement, so that all 
possible sources of irritation of the injured tissues are eliminated. 

In a very septic wound some provision may have to be made for con- 
tinuous douching, baths or irrigation. In many cases treatment is carried 
out by Stannard’s silk-coated envelope (see p. 577). In addition, the 
gener^ health of the patient should be attend^ to; a foiu'-hourly record 
of his temperature and pulse should be taken; his excretory channels should 
be kept in regular action and his diet should be nourishing and liberal. 
He should have adequate rest and sleep. The sulphanilamide compounds 
are usehd in some cases. 

Sulphonamide powder. During the last few months powdered sulphona- 
mide (sulphanilzunide and sulphathiazole) has been applied to the raw 
surfaces of infected wounds; and the result is considered encouraging. 
All sloughs, dried exudate and dried pus are gently removed, and when 
the surfaces are clean, finely powdered sulphonamide is lightly insufflated 
on the wound; heavy powdering is not necessary. Either a light gauze 
dressing or tulle gras is then applied, and this is covered by sterilized oiled 
silk or jaconet to retain moisture. The dressing is changed once daily, 
the gauze being sprayed or soaked with saline or Milton to prevent 
trauma. 

In some cases oral administration of sulphonamides (see p. 328) is 
employed in conjunction with local application. 

INJURY TO TENDON, NERVE AND MUSCLE 

Tendons, nerv« and muscles may be injured by die various types of 
wounds described on p. 577, In a wound of the front of the wrist for 
example, such as may arise in a serious street fight, or in mutiny on board 
ship, the flexor tendons to the hand will probably be severed, and the 
mMian and ulnar nerves may be cut throt^fh. 



INJURY TO TBNDON, NERVE AND MUSCLE 583 

In the immdittit trmtnmt ofsudi sua injury careful investigation would be 
made of the structures which had been divided and these would be 
brou^t togetho:* and sutured if possible. 

Rupture of a muscle dr tendon may arise as the result of a severe 
strain or a wrenching movement. A portion of triceps muscle is sometimes 
ruptured in vigorous movement of the elbow. Plantaris is the muscle most 
easily juptured in the calf of the leg in violent movement in running and 
springing as practised, for instance, in a hard game of tennis. 

The result of rupture of a muscle, even if only a few of its fibres are tom, 
causes pain which is accompanied by tenderness and swelling. 

The treatment is rest by any means by which the affected parts can be 
kept in a position of relaxation. Strapping may be sufficient in some 
cases; in others a splint or plaster of paris will be applied. Rest must be 
maintained for from lo to 21 days, according to the amount of injury, 
and it must be sufficiently long to ^ow the torn muscle fibres to heal. 

Teno- synovitis, or inflammation of a tendon and its sheath, may be 
caused by an injury such as a blow, and may result in a mild degree of 
inflammation. It may also arise when injury by stretching occurs to the 
tendons in the vicinity of a joint, when the joint is dislocated or sprained. 

The smptoms of teno-synovitis are pain and swelling, and a grating sound 
is heard on movement of the tendon. The condition is treated by applica- 
tions of heat in the first instance, in order to relieve the pain, and the 
affected tendon must be kept at rest as described in the treatment for 
rupture of a muscle. 

STINGS AND BITES 

A sting by a wasp or bee often causes considerable local pain and 
swelling, and in some instances it is accompanied by shock. In treating 
this, it should first be ascertained whether the sting has been left in — 
a bee usually leaves its sting in the tissues, but a wasp extracts it. 

Having removed the sting an alkali should be applied — either a soda 
or a maraesium sulphate compress is useful; if glycerine of ichthyol is 
obtainable an application thereof will relieve th’e tension and pain more 
rapidly. 

The bite of the adder is about the only injury which need be con- 
sidered as regards poisonous reptiles in this country. This needs treatment 
at once, or the poison will be absorbed and, entering the blood stream, 
will act by depressing the vital nerve centres controlling respiration and 
cardiac action. 

In the immediate treatment, if the part bitten is a limb, it should be con- 
stricted above the injury to prevent the venous blood from returning to 
the heart with its load of poison; the skin should be incised with a sharp 
instrument and the blood squeezed out; the best application to make is 
permanganate of potash but, not expecting snake bite, persons do not 
cairy this with than — many, however, do carry iodine and it may be 
employed instead. If any form of suction, other than sucking by mouth 
and spitting out the venom, is available, it should be used — it may be 
possible to improvise some fbrm of cupping. Hot wet dressii^ may also 
be mplied. 

When the patient can be taken to the surgery a doctor the bite will 



584 INJURIES TO SOFT STRUCTURES 

be incised and permanganate of potash applied, followed by hot fomenta- 
tions. 

The general condition of the patient must be observed, and he should be kept 
as still as possible (exercise and movement are contraindicated), and warm 
in order to minimize the shock. He should be g^ven stimulants, such as 
whisky and brandy, and ammonia in the form of sal volatile; if his respira- 
tions become very slow, artifical respiration must be performed. 

Bites of the dog are always accompanied by fear of hydrophobia, even 
though this is a very unlikely complication nowadays. If the skin h^ only 
been grazed no special treatment is needed; the abrasion will be dressed 
in the usual way with some antiseptic. If the dog has bitten into the tissues 
the wound should be carefully cleaned and cauterized with nitrate of silver. 

Bites of other animals, such as cats and horses, may give rise to infection 
and therefore the wounds inflicted ought to be treated like any other 
wound which is liable to become infected. 

FOREIGN BODIES IN THE TISSUE 

A needle may penetrate the tissues, or a person may step on and get a 
needle in his foot, or he may sit on a needle and get it into his buttock. 
Unfortunately the needle moves freely along the muscle sheaths once it is 
embedded in the tissues, and the only way to prevent this from happen- 
ing is to keep the part at complete rest until help can be obtained. If 
the needle has not disappeared, it can possibly be withdrawn; and when 
it has disappeared, advise the patient to keep still and, if it is in a part 
which can be splinted such as the foot, some form of splint might be 
applied; this should control the knee joint as well as the ankle joint, as 
movement of the knee will cause movement of the muscles controlling the 
foot. 

The position of the needle will be determined by special X-ray examina- 
tion, and the surgeon will operate and remove it. 

A splinter in the soft tissues requires similar care to that described 
above; it may not, however, be deeply embedded. When superficial, the 
tract made by the splinter should be opened and the foreign body 
removed. 

A foreign body in the eye may take the form of a particle of dust or 
grit on the conjunctiva. The eyelids should be everted and the particle 
removed by means of a soft swab; if the particle is sharp and is pricking 
badly, a little castor oil should be inserted before an attempt is made to 
remove it. 

When the foreign body is on the cornea, its removal requires much more 
care; the cornea is very sensitive, and the eye will have to be anaesthe- 
tized by the insertion of cocaine before any attempt can be made to remove 
the object. The average nurse should not attempt to do this; she should 
merely cover the eye with a pad and take the patient to a doctor at once. 
Having cocainized the eye he will inspect it carefully with the aid a 
magnifying lens, and if the particle is on the surface of the cornea it may 
be p^ible to remove it with a small pad; if embedded in the cmnea 
he wUl need a small instrument to dig it out; if the particle is metal, the 
use of a magnet may be tried. The nurse who deals with a patient, rfter the 
removal of ei foreign body from the structure of the cornea, will be required to 



FRACTURE OF NECK OF HUMERUS 


585 



Fig. 194 . — see chapter page 595. 

Dislocation of the Head of the Hu^lcrus as a result of a comininuled 
Fracture of the surgical neck. The head of the humerus is seen 
displaced downwards. The great tuberosity of the humerus is 
separated and the bone in the vicinity of the surgical neck is broken 
into several pieces. 


586 


FRACTURES OF FOREARM 



Fig. 195. Fig. 19(3. 

Greenstick fracture of Colles’s fracture of the lowtT end of radius, 

both bones of forearm. 


Fig. 197. CoLLEs’s Fracture. 

Lateral view showing deformity due to displacement of bone. 


FRACTURE OF NECK OF FEMUR 


587 



Fig. 19B. Intracapsular fracture of 
the Neck of the Femur. 



Fig. 199. 

The same patient as in Fig. 
198 after reduction of frac- 
ture and insertion of a 
Smith-Pctersen pin. 



588 


FRACTURES OF TIBIA AND FIBULA 



Vic;. 200. Pori’s I'racti-kk. 

A badly roniTniniited lN>tt’s Irarlurr, i.r., a iracturc of the lower third 
of the shaft of the fibula. In this illustration the til)ia also is broken and 
the ankle is dislocated upwards and backwards (,ur aLso Fig, 201). 


FRACTURES OF TIBIA AND FIBULA 


589 


■!? 



1 ^ 10 . 1201 . 

Tiic sanit* patient as in Fit^. -joo aft^*i 
operation ri>r the reduction of fractures and 
dislocation which included wiring the 
i'ragrnenls to maintain them in position. 



590 


FRACTURES OF TIBIA AND FIBULA 



Fig. 202. I'^RAcrrcRKD Tibia and Fibitla. 
A comminuted fracture of both tibia and 
fibula extendinjE^. in the case of the tibia, 
into the knee joint. Note that tlic breaks 
in tiie tibia are both oblique and longi- 
tudinal. 



FRACTURES OF TIBIA AND FIBULA 


591 



Fkj. 203. Fig. 204. 

Transverse fracture of tibia Fracture of tibia and fibula 

and fibula. with slight displacement. 



592 


FRACTURE OF SPINE 



Fracturk-Dislocation affecting 
Fig. 205. 

View of the spine X-rayed with 
the patient supine. The front of 
the vertebral bodies is on view 
and the amount of lateral 
displacement can be seen. 


TWO OF THE Ll MBAR VeRTEBRAE. 

Fig. 206. 

Lateral view of the spine in the . 
patient as Fig. 205. 



IN THE TISStJE 593 

iirrigate the eye with weak boracic lotion twice a day; to insert atropine 
in order to keep the eye at rest, and to keep it covered with a comfortable 
eye pad. The patient should be seen by his doctor at regular intervals for 
some time to ensure that the comcal abrasion is healing. 

The result of a foreign body la the ear is usually pressure, inflam- 
mation and ulceration. Children often put beads, peas, nuts and other 
small objects into the car. A nurse should not attempt to remove a foreign 
body from the ear, as any attempt will usually result in pushing the article 
farther in; if she syringes the car, hoping to remove the object, she may 
only result in making it larger, and so increase the pressure, since if it is of 
a vegetable nature such as a pea it will swell when wet. 

She should take the child to a doctor, reassuring both child and mother 
that there is no immediate danger. The doctor wfll examine the ear with 
a speculum and head mirror, and he may then remove the object either by 
syxinging or by means of some small special instrument. When the foreign 
body has been removed he will inspect the drum to sec that it is intact, 
and carefully cleanse the meatus with small swabs, leaving it quite dry 
and he may perhaps insert a tiny piece of cotton wool. 

Nose. Similar foreign bodies may be placed by a child in his nose; the 
child then probably forgets all about it. Some weeks later, the mother 
notices a discharge from one side of the nose, due to the inflammation 
brought about by pressure of the foreign body, which if left will lead to 
ulceration of the lining of the nasal cavity. It would be unwise for a nurse 
to attempt to remove a foreign body from the nose in the circumstances 
suggested above — she should take the child to a doctor. He will insert a 
nasal speculum and sec where the article is, and then, having first co- 
cainized the membrane, he will pass some small instrument behind the 
obstruction and so attempt to remove it. 

If someone actually saw the child put the foreign body up his nose, a 
nurse might attempt to remove it immediately afterwards; she must 
remember, however, that this can only be successfully done by means of 
pressure from behind; she should therefore get the child to blow his 
nose and she might give a nasal douche, via the opposite nostril, hoping 
the return flow down the obstructed side will bring the foreign body 
down with it. She should never attempt to remove it from the front by 
means of forceps, as the instrument will only slip off and push the obstruc- 
tion farther up. 

A foreign body in the larynx produces alarming symptoms of suffo- 
cation and asphyxia and the patient may become black in the face. In 
such a case a nurse should send at once for a doctor, and in the meantime 
put her finger into the patient’s throat and try to dislodge anything which 
may be there — ^very often a piece of food. She might also slap the patient 
forcibly on the back hoping to dislodge any foreign body from the chink 
of the glottis. If these means are not successful she should collect the 
articles required for tracheotomy — these are always ready at hand in the 
casualty department of a hospital. The doctor, when he arrives, will 
probably perform tracheotoiny at once. It is useless to attempt artificial 
respiration when the respiratory passages are blocked. 

Foreign body In the oesophagus. The foreign bodies which most 
often get fixed in the oesophagus arc either a fishbone or a dental plate. 



594 INJURIES TO SOFT STRUCTURES 

If the article is just behind the mouth, in the pharynx, it may be possible 
to remove it with the fingers. .^lart from this, a nurse idiopld not attempt 
to remove a foreign body from the oesophagus; the condition is very 
dangerous, the oesophagus is a fine tube, very ea^y ulcerated, and this 
will cause mediastinitis and pneumonia. 

The doctor who is called in to deal with diis case will require an 
X-ray examination to be made, and when the position of the objec;t has 
been ascertained it may be possible to remove it by means of ocsophagos- 
copy. 

After such treatment the patient will be kept on food which can be 
easily swallowed, in order to prevent irritation and any resultant injury 
to the lining of the oesophagus. 

Foreign body in the urethra. Children sometimes push pins or other 
fine objects into the urethra, or a glass catheter may be broken in it when 
a female patient is being catheterized. The nurse should not attempt 
to remove a foreign body from the urethra; she should prepare some fine 
forceps and a good light which the doctor will require for this purpose. 



Chapter 39 

Injuries to Bones and Joints 

Fractures: predisposing and exciting causes^ varieties of fracture^ ^mptoms and 
signs f healing and repair ^ complications — Fractures of the skull: symptoms of frac^ 
ture of the base^ treatment and nursing — ConcussioUy compression and cerebral irri- 
tation: observation^ treatment and nursing care — Fractures of the spine: signs and 
^mptoms^ treatment and nursing — Fractures of the pelvis — Injuries to joints: 

sprains and dislocations 

A bone may be bruised or broken and, when it is bruised, blood is extra- 
vasated into the periosteum, causing swelling, tension and pain. 
^ Even a slight blow on a bone, especially in children, may be com* 
plicated by sepsis and, beginning with a little periostitis, it may progress 
to osteomyelitis and the child become exceedingly ill within 24 hours, 
with a high temperature, rapid pulse and mark<5i prostration. 

In such a case it is necessaiy to operate at once, incising the bone and 
draining the medullary cavity. This will prevent the danger of septicaemia 
with which the patient is threatened. 

A kick on the shin which results in a bump is a periosteal bruise; the 
extravasated blood may either become absorbed or fibrous tissue may form 
which results in a hard lump persisting for some time. A subperiosteal 
haematoma may form, this being most commonly met with in the case of a 
blow on the skull. 

An uncomplicated bruise on a bone will usually respond to applica- 
tions of heat which will help to relieve the pain and promote absorption 
of the fluid under the periosteum. 


FRACTURES 

For various types of fracture see figs. 194-206, pp. 585-592. 

The causes of fracture may be divided into predisposing and exciting 
causes: 

Predisposing causes. Many local diseases of bone and some general 
diseases predispose to fracture. Local diseases include tuberculosis, inflam- 
matory lesions such as osteomyelitis, primary tumours of bone and 
secondary carcinomatous deposits in bone. Cancer of the breast, thyroid, 
kidney and prostate gland may be extended by means of the blo^ stream 
to bone, the commonest sites of secondary carcinoma in bone being the 
spinal column and pelvic bones. 

General diseases of bone which most commonly predispose to fracture arc 
rickets and Paget’s disease. Paget’s disease b characterized by erosion of 
the bone, nature attempts to replace the eroded bone, with the result that 
a largt s^t mass is formed with a tendency to bending of the bone — only 
later does hardening occur. 

Certain nerve diseases also predispose to fracture, including general paral- 
ysis of the insane and locomotor ataxia. Extremes of age are another cause; 
the soft bones of an infant give rise to the greensdek fracture; the brittle- 

595 



596 INJURIES TO BONES AND JOINTS 

ness which characterizes the bones of old persons also predisposes to 
fracture. 

Exciting causes are usually described as being those of direct violence 
such as occurs in a crushing accident; or indirect violence when the force 
applied is transmitted along a limb. Pott’s fracture, which happens when 
a person slips and the fibula is broken about three inches above the ankle 
joint, is an example of the latter. Another example is the breaking of a 
collar bone by failing on the outstretched hand; the force is then trans- 
mitted along the arm to the collar bone. A CoUes’s fracture, fracture of the 
lower end of the radius, sustained by falling with the hand outstretched, 
the force striking the palm of the hand, is yet another example. 

Muscular violence causes a fracture when a large muscle forcibly contract- 
ing breaks a bone. The best example of this cause is fracture of the patella 
— ^a person may, for example, trip and, in order to save himself from falling, 
forcibly extend his knee by contraction of the quadriceps extensor muscle, 
resulting in a transverse fracture of the patella, the bone being divided into 
two, one half remaining attached to the patellar ligament and the other 
to the quadriceps muscle. 

Varieties of fracture. A fracture may be simple or closed or compound or 
open. A simple fracture is described as closed b^use there is no opening 
in the skin; the bone is not seen protruding through the skin as it is in a 
compound or open fracture, but a simple fracture may become compound 
by injudicious handling, if splints arc not properly applied the bone may 
be forced through the skin. 

A fracture may also be complete when the bone is broken right through, 
or incomplete when it is not completely divided. Examples of a complete fracture 
are described according to the shape of the break, which may be T-shaped, 
spiral, oblique or transverse. A complete fracture may also be described accord- 
ing to the typ>e of damage done to the bone — when two or more breaks 
occur, it is said to be comminuted-, it may also be splintered. When the ends of 
the broken bone are driven one into the other, the term impacted fracture 
is used to describe the break. 

Varieties of incomplete fracture arc the greenstick already mentioned, and 
in this type the bone bends, like a green twig, but is not broken right across. 
Depressed fracture occurs of the bones of the cranium and face; the bone is 
struck and indented like the injury done to a boiled egg when it is struck 
on top with the ball of a spoon. Fissured fractures also most often occur in 
the bones of the cranium and other flat bones — the bone is split and 
fissured, but the parts arc not separated or completely divided. 

Symptoms and signs of fracture. The signs and symptoms asso- 
ciated with local injury — bruising, sxvelling, tenderness and pain — ^will be 
present. Blisters may arise on the skin over the fracture. Other special signs 
of fracture are deformity, which varies and may be slight or severe; there 
may be overriding of the ends of the broken bone causing shortening of 
the limb and marked thickness at the site of fracture; angular displace- 
ment may also occur. 

Abnormal mobility — the normal alignment of the limb is interrupted and 
therefore the part below the break can be twisted in any direction. 

Crepkus k the grating soimd produced when the broken ends of the bone 
rub togedier. Neither crepitus nor abnormal mobility will be present in 
mi incomplete or impacted fracture. 



FRACTURES 597 

The apptearance of the fracture when expo^ to X-ray examination 
will help to complete the information desired by the surgeon regarding the 
case he is examming. 

Treatment. The Jirst-aid treatment is important, as its efficiency may 
prevent a closed fracture from being changed into an open fraOpirc. 
Some form of temporary fixation must be applied before the patient can 
be moved; any improvised splints that are used should control the move- 
ment of the joints both above and below the break. They should be firmly 
but not too tightly applied, and should be firm enough to prevent move- 
ment of the ends of the broken bone during transit from the site of the 
accident to the doctor’s sui^ery, or to the casualty department of a hos- 
pital. 

Reduction of deformity is carried out when the fracture is set and the ends 
of the bone are brought into apposition. A general anaesthetic may be 
necessary during this procedure. 

Fixation of the position adopted is necessary until healing has taken 
place. This may be maintained by means of splints or plaster of paris. In 
some cases extension will be necessary in addition (see also p. 224). 

Healing or repair of a fracture. Healing is brought about by the 
formation of callus, which is granulation tissue of bone; it contains latent 
osteoblasts, and these cells take calcium from the blood and so bone is 
formed. At first the mass called callus is solid bone, but in time other cells, 
called osteoclasts — ^which are bone destroying — come into action and thus 
the canals and spaces necessary in bone are provided. 

Factors necessary for good repair. The bone ends should be in fair apposition; 
there must be reasonable immobility in order to furnish the necessary 
rest; there must be freedom from infection; the patient’s general health 
should be good and calcium should be provided if thought necessary. 

For perfect success, restoration of the function of the limb, and of the 
joints near the break particularly, should be ensiured by massage of tlie 
muscles and by passive and active movements of the joints. 

Nursing care. It is necessary to understand the principles of treatment 
of fractures, as successful results depend on the correct application of 
these. The nurse will have to see that the splints or extensions that are 
used are maintained as they were intended in order to immobilize the 
fracture adequately. A patient with a fracture of the lower limb, for 
example, will be obliged to lie very still; he may be nursed on a firm 
unyielding surface, as when fracture boards are placed beneath the mat- 
tress on which he lies. This predisposes him to two possible complications : 

( 1 ) bedsores because of the hard surface on which he is forced to lie, and 

(2) lypostatic congestion of tiu lungs, particularly if the person is middle Rged 
or elderly. 

A little traumatic feoer, indicated by a slight rise in temperature, inability 
to sleep and loss of appetite, may be expected to arise after any seiickus 
injury. iSAocA may be present when the injury has been severe, and this will 
need treatment by means of applications of external heat, and the adminis- 
tration of fluids; the surgeon will usually order the patient to be given some 
morphia. 

The patient may find it difficult to sleep, or to pass urine and faeces in 
bed in the very limited and unusual position in which he is probably 



598 INJURIES TO BONES AND JOINTS 

forced to lie; the splints or <ractensiohs may be uncomfortable and, unless 
properly guarded, there is danger df pressure sores. Sleeplessness may give 
rise to wandering and delirium, while in chronic alcol^ics delirium tre- 
mens may occur. 

The digestion may be impaired for some days; the patient may suffer 
from flatulence and loss of appetite, and he should be given plenty of 
fluid and may have a light or a full diet as soon as he wishes to eat. His 
bowels should be regulated, if necessary, by some mild laxative such as 
liquid paraffin. 

Complications of fractures.. Shock, traumatic fever, bedsores, hypostatic 
prmtmotda, and delirium have already been mention^. 

Mal-union or non-union are probably those most dreaded by a surgeon. 
In non-union the bone does not unite, and this may be due to debility of 
the patient or to too little calcium in his blood. It may also arise as the 
result of faulty splinting, which allows movement and so prevents the 
repair of bone. It may be the result of sepsis, but may also be met when the 
gap between the ends of the broken bone is very wide, so that reasonable 
apposition is not possible. 

Mal-union complicates, most often, fractures near a j'oint, particularly 
the elbow and the ankle joints, and it results in marked deformity. 

Stiffness and rigidity following a fracture, particularly when near a joint, 
may be sufficiently marked to constitute a complication; treatment by 
massage and movement during the time the patient is under observation 
is employed in order to prevent the occurrence of this. 

Paralysis and contracture. Sometimes, when a nerve is embedded in the 
callus which forms in the healing of a fracture, temporary paralysis may 
be met. As the excess callus is removed this will usually disappear; in the 
meantime, the affected part is treated by massage and electrical stimula- 
tion. Crutch palsy, which is paralysis of the posterior cord of the brachial 
plexus and therefore affects the muscles supplied by the musculospiral 
nerve, may be brought about by the injudicious use of badly fitting 
crutches but it never ought to occur. Volkmann's schaemic contracture is due 
to the destruction of muscle and its replacement by fibrous tissue owing to 
the too tight application of splints. This is very rarely seen, but when it 
does occur the anterior aspect of the forearm is the partlosually affected. 
In a fracture of the bones of the forearm of a child a splint is applied, the 
parts beneath the splint swell, causing tension and pressure, but unfor- 
tunately the tiny child does not complain and when the splints are 
removed this complication may be found to be present. 

FRACTURES OF THE SKULL 

Either the vault or the base of the skull may be fractured, or both parts 
may be involved in the injury. 

Fractures of the vtadt of the skull may he fissured, depressed or punctured, and 
the treatment depends on the extent of injury to the brain. In a fissured 
fracture there may be iew symptoms and but little injury; when a de- 
pressed fracture occurs the indented portion of bone presses on the con- 
tents of the cranium and gives rise to symptoms of cerebral compression 
(see p. 6oi). 

Fracture of the base of the skull may be produced directly, when the blow 
falls upon the base, either as the result of an injury to foe lower jaw, the 



FRACTURES OP THE SKULL 5^ 

nose or the roof of the mouth, or by an injury to the spinal coiunrn which 
forces it up against the base of the skull; or it may be produced indirectly 
as when a blow directed on the vault does not break one of the flat bones, 
but is transmitted to the irregular bones at the base of the skull, resulting 
in fracture of this region. 

The symptoms of a fracture of the base of the skull vary according 
to the amount of damage done to the brain. The patient may admitted 
in a stuporous or unconscious condition or he may be wandering and 
delirious. Compression of the brain wiU give rise to paralysis of the Oppo- 
site side of the body, including in most cases the face; the breathing will 
be deep and stertorous in character and the pulse, unless considerable 
shock is present, will be full and bounding and slow. Certain eye changes 
may also be seen, including squint and inequality or irregularity in the 
size of the pupils. There may be bleeding into the conjunctiva, or around 
the cavity of the eye, or from the nose or ears. A discharge of watery fluid 
from the ears indicates that cerebrospinal fluid is escaping through an 
injured dura mater. 

Treatment and nursing. The patient is placed flat in bed and kept 
in a quiet, slightly darkened room, in order to eliminate sound and bright 
light which would be sources of irritation to the injured nerve matter. A 
cold compress or icebag is usually placed on the patient’s head and he 
may have some external heat applied over the lower extremities — ^such as 
an electric cradle — but, as he may be restless and is not respxsnsible for his 
actions, great care should be taken to prevent the occurrence of bums. 

A careful record, every half-hour at first, is made of the character and 
rate of pube and respiration; the temperature is taken every 4 hours, 
unless it is found to be rising rapidly when it should be taken at one- or 
two-hourly intervals, as this is a vexy serious happening. 

At the outset some drastic aperient is invariably ordered; if the patietit 
is only stuporous and can swallow, he may either be ordered 3-5 grains of 
calomel or i minim of croton oil; it is advisable to place suitable wool and 
tow pads beneath the patient in order to avoid soiling of the bed if his 
bowels should act without warning. Even though a patient is apparently 
imconscious any slight movement which he may make after the adminis- 
tration of an aperient would probably indicate that it was about to act, 
and the insertion of a bedpan as soon as this observation was made would 
probably prevent the passing of faeces in the bed. . 

A specimen of urine should be tested as soon as one is obtained, and it is 
necessary to watch carefully for any indication of retention, since a patient 
who apparently has incontinence of urine may merely be dribbling 
urine away from an overloaded bladder. The bed of a patient with a frac- 
tured skull should always be adequately proteoted by mackintoshes, and 
care should be taken to prevent the formation of bedsores. 

During the first 24-48 hours diet or even fluid is considered compara- 
tively unimportant, butif a patient can be easily roused to swallow he may 
be pven drinks of water or glucose in lemonade. Probably long before 
this time has elapsed the surgeon will have decided whether any surgical 
interference is called for and will carry it out if necessary. Alternatively, 
the patient may be doing wdl and by this time be able to take nourish- 
ment; if not, rectal saline containing glucose will be ordered. 



60O INJURIES TO BONES AND JOINTS 

Durang all this time the mirse should be obsendng her patient very car^ 
fully for tmy increase or decrease of the symptoms outlmed -above. It is 
necessary to attend to the mouth at frequent intervals, and the ears, nose 
and eyes should receive any attention they need; if discharge is present 
the character should be observed, and discharge from the ears particularly 
should receive very careful attention; in serious injuries to the dura mater, 
the nurse may notice tiny pieces of the grey matter of the brain escaping 
in the cerebrospinal fluid which is coming away. The amount of moisture 
escaping from the ears should be carefully reported upon. 

In some instances bleeding occurs from the back of dke nose and trickles 
down the throat; a conscious patient will be seen swallowing, but in the 
case of a patient who is unconscious this blood may be trickling into the 
respiratory passages where, in the lung, it will give rise to serious inhala> 
tion pneumonia in a day or so. 

The nurse should be very familiar with the points to which attention 
must be paid in the nursing of any patient who is unconscious; these arc 
described in more detail on pp. 754-5. 


CONCUSSION, COMPRESSION AND CEREBRAL 
IRRITATION 

When a patient is admitted with an injury to his head it may be difficult, 
at first, to ascertain whether the injury has only resulted in shock to the 
brain matter, or whether definite injury to it has been sustained, and it is 
very necessary that a nurse should be quick to recognize the symptoms of 
concussion and that she should be able to note the changes which will 
occur in the patient’s condition should cerebral compression follow. 

Concussion may produce only slight symptoms of natisea and dizziness, 
a vague inability to recognize the surroundings in which a patient finds 
himself, and slight confusion of mind; there may be a short interval of un- 
consciousness. When severe, concussion will be accompanied by uncon- 
sciousness, but usually the patient is only in a state of stupor and not in 
coma. He could be roused H shaken and spoken to, but it is not advisable 
to attempt this as there is always the danger of cerebral irritation following 
a state of concussion, which will be aggravated by any stimulation of the 
patient. 

Signs and symptoms. When a patient is admitted with a diagnosis of con- 
cussion the nurse should expect to find him lying limp and flaccid, with 
a soft, fairly slow and rather smadl pulse, subnormal temperature, ctJd 
clammy skin and with rather shallow slow respirations. These symptoms, 
she will recognize, are very similar to those orshock, and this is because 
any serious shaking of the brain, described as concussion, gives rise to 
shock and, for the time being, the patient is in a cold, debiUtated state. 

Observations, treatment and nursing of concussion. The patient 
is received into a warm bed, but should not face the light; he should not 
be given hot water bottles as he is likely to move involuntarily and may 
come into contact with one and be ittjunsd. He may have one low pillow 
under his head, and as a rule an icebag is ordered to be applied to the 
head. It is advisable to protect the bed with mackintoshes in ease the 
patient passes urine involuntarily whilst in the state of fliaecid panvity; 



CONCUSSION 6oi 

the pillow should also be protected, as when the patient begins to improve 
he invariably vomit. 

A period oj reaction occurs as a patient begins to recover from concussion; 
he has previously been cold, but his temp>erature now rises to or ioo° 
F. and his pulse improves in volume and rate; his colour, previously pale, 
imfxoves and his face becomes dightly flushed. Hitherto he has been 
lying flat and limp in bed, but he now puts his hand to his head as it aches, 
and turns over, curling his head do\m and drawing his knees up, and 
usually he vomits. From this time onwards he is restless, complaining of 
headache and slight nausea; as improvement continues he will ask for the 
urinal or bedpan and usually inquire the time, and ask for a drink. He 
may then be satisfied and apparently sleep at intervals, and it will now 
be most important to avoid all irritation, by touch, sound or light, as at this 
period the dreaded complication of cerebral irritation may make its 
appearance. 

Durii^ the following days die patient should rest in bed, his bowels 
should kept active, his urine be measured and tested and the bladder 
watched, as retention of urine may occur. He may have drinks at first and 
li^t diet if he is willing to eat. 

Headache often persists and cold applications to the head are continued 
for its relief. Lumbar puncture may be performed with the same object, 
and analgesic preparations are sometimes ordered. The administration 
of hypertonic solutions of magnesium sulphate j>cr rectum are also 
sometimes employed, as by producing dehydration this will relieve intra- 
cranial pressure. 

During her nursing care of a patient with concussion the nurse must 
be on the look-out for any indication of either cerebral compression or 
irritation (see notes below). 

Compression is more serious than concussion, because the brain is 
either pressed upon or injured, whereas in concussion it is only shocked 
or shaken. 

The symptoms and signs of compression may come on gradually, or the injury 
may have been so severe at the outset that compression occurred immedi- 
ately. In severe compression the patient is in a state of coma; his breathing is 
deep, stertorous and noisy; his pulse full and boimding and usually slow, 
and his temperature may or may not be raised; hb face is usually flushed 
and he lies drawing hb cheeks in and out with each deep act of respiration. 
On inspection of Ws eyes the pupils may be found to be unequal in size 
and there may be a squint; examination of the limbs may result in finding 
that one faUs more limply than the other when rabed ^m the bed and 
allowed to drop back again — indicating paralysb of one side. There may 
be incontinence of urine and faeces, or retention of urine may be present, 
and the abdomen may be dbtended by retendon of gas in the intestine. 

Observation, treatment and nursing care. The patient b received 
into bed and hb bead b kept flat, an icebag bong applied to it; immediate 
observation b made of hu condition which should be written down so 
that further observations can be made as they occur and any change 
accurately noted. 

The mirse will make observations similar to those in the case of a firacture 
of the skull, watching the pube, breathing and temperature, the eyes for 
cotain (Ganges, and the nose and can for any discharge. Dangerous signs 



6o2 injuries to bones and joints 

whkh may arise incliide alteralaon of the breaking, with increase in the 
irregularity and depth, or the breathing may broome of the Cheyne* 
Stokes type. Any increase or decrease in the rate of die pulse should be 
observed, a rapidly ri^g temperature which may reach 105° F. or over 
being particularly serious. 

Either a magnedum sulphate enema or a dose of one minim of croton 
oil will usually be ordered on admission, and a specimen of uiine should 
be tested as soon as one is obtained. The mouth should be kept clean, 
bladder infection and bedsores prevented, and in cases of coma, the eyes— ^ 
because they arc sometimes widely open and the conjunctival reflex 
abolished — should be bathed regularly to prevent infection. (For further 
details of nursing see nursing care in cases of unconsciousness on p. 754.) 

Cerebral irritation may follow concussion or complicate compression. 
In this state the patient is conscious, though he may be very surly and 
refuse to rouse or move. Whenever any necessary treatment is performed, 
as makir^ the bed, cleaning him and so on, he shouts, and curses, and 
becomes very violent, even lacking and biting his attendants. This may go 
on for some time, and gradual recovery then takes place, leaving the 
patient mentally confused and dazed, with severe headache and in some 
cases loss of memory. 

The treatment is rest, avoidance of irritation, and relief of intracranial 
pressure if this is suspected. A patient who has suffered from cerebral irrita- 
tion needs a long rest during which he should have a nourishing but non- 
stimulating diet; his bowels should be kept in regular action by the use 
of a saline aperient each morning; he should not be subject to worry and 
anxiety and should be kept under observation for several months. It is 
inadvisable to allow him to go out alone for some time, as he may have a 
recurrence of loss of memory with very distressing results for himself and 
his relatives and friends should he wander off and be lost for a time. 

FRACTURES OF THE SPINE 

The spiru may be fractured by direct violence, as usually happens in a 
serious crushing accident; or it may be fractured indirectly, as when a 
weight falls upon the head and shoulders — the spine, unable to adapt itself, 
snaps. In very many instances a fracture-dislocation occurs, and when this 
happens the cord may be crushed between the displaced vertebrae. 

SigQS and symptoms. At first there is spinal concussion; a patient 
admitted with a fractured spine will be pale and cold, with a small rapid 
pulse and shallow breathing; there will be total loss of piower in the 
muscles of the parts below the site of fracture; sensation may also be 
completely absent, or it may be only impaired. In most instances at this 
stage there will be loss of power over the sphincters of the anus and urethra 
with total incontinence; in some cases, however, there may be retention 
of urine. 

The higher up the spinal column the fracture occurs, the greater will 
be the disability and danger. In a fracture of the cervical region the arms, and 
the body below this, will be paralysed; the pupils of the eyes will probably 
be aflfected as the cervical sympathetic nerves are given off from ganglia 
in the cervical region; the phrenic nerves may also be injured; if ba^y, the 



rRA,CTU.RE8 07 THE SPINE 603 

diaphragm will be but of action and if the diapfara^ is totally paralysed 
the prognosis is 'very grave. 

Fractures of the dorsal region will result in paralyds of the trunk below ^e 
fracture and of the lower limbs. The intercostal muscles below the lesion 
will be paralysed so that breathing will be slightly interfered with. Fracture 
of the lumbar region will result in paralysis of the lower limbs with involve- 
ment of the organic reflexes controlling micturition and defecation. 

The usual signs of injury may be present locally, and there will be bruis- 
ing and swelling and possibly deformity also. 

Treatment and nursing. On admission it is necessary to get the 
patient into bed as rapidly as possible and to treat the degree of shock 
present. If possible he should be placed on the bed on which he will be 
nursed; some surgeons advocate a firm unyielding surface with fracture 
boards beneath the mattress; in this case a full size air bed will usually be 
employed in order to prevent sores from forming as the result of lying on 
the hard surface. 

The use of a sectional mattress makes it possible to attend to the patient’s 
back and to put the bedpan in and out without moving him. Other sur- 
geons immobilize the spine by means of a plaster of paris bed as soon as he 
has recovered from the initial shock from which he may be suffering. 

The principles to be considered in the treatment of cases of fracture of the spine 
depend entirely on whether the spinal cord is injured or not. In cases 
where the cord has escaped injury the application of a plaster of pans 
spinal jacket with the spine fully extended will separate the crushed bodies 
of the injured vertebrae, prevent the occurrence of any injury to the cord 
subsequent to the fracture and lessen the period of complete rest in bed. 
A patient with a fracture of the dorsal region for example will have a spinal 
jacket applied to keep the spine extended and should be able to walk 
about, wear his ordinary clothes and follow his occupation, in many in- 
smnees, a week or 10 days after the injury. Similarly a case of fractiurc of 
the lower cervical or upper dorsal vertebrae, uncomplicated by injury to 
the spinal cord, may have a spinal jacket applied with the head fully 
extended. 

On the other hand when there is injury to the spinal cord the period of 
immobilization in bed is often very prolonged and the prevention of in- 
fection of the bladder, of bedsores and trophic sores and hypostatic pneu- 
monia calls for very careful nursing throughout. 

The bladder needs careful observation; there may be incontinence or 
retention of urine. The latter may be treated by regular catheterization 
or by inserting a self-retaining catheter or by one of the means described 
on pp. 142-3 of intermittent bladder drainage. The surgeon will usually 
order some form of luinary antiseptic to be given and he may also have 
ordered a mild diuretic at the outset; the nurse should provide her 
patient with plenty of bland fluids and see that he takes at least 6 pints 
in 24 hours, including barley water, lemonade and water. 

Constipation and abdominal distension may be very troublesome; partly be- 
cause the patient is lying flat and partly because some of the nerves supply- 
ing the muscles of the abdominal wall may be invcJved. As a rule the 
bowel will be emptied by means of an olive oil enema; this may be 
repeated daily, or mild laxatives may be given in an attempt to keep the 
bowd active, supplemented by cnemata as found necessary. 



6o4 injuries to bones and joints 

The prmniion of bedsores tmd abrasions of the skin is also very iinportant; 
at first sensation will be impaired, but it is to be h(q>ed that improvement 
will occur in dus respect. As a rule much of the impairment of sensation 
present at the outset may be associated with spimu shock and bruising 
of the cord which will disappear in time. 

Ordinary routine nursing measures should be employed, but it has also 
to be remembered that the trophic nerves to the i^n may be impaired, 
and that injury to the skin will very easily occur; for this reason the patient 
should never be rolled or turned to have his sheet changed as this move- 
ment may be sufficient to abrade the surface of the skin — instead, he should 
be lifted. 

If the pressure of the bedclothes appears to redden or injure the skin, or 
is likely to do so, either a bedcradle ^ould be inserted to Udce the wdght, 
or the parts affected should be wrapped in cotton wool bandages, but 
these ought to be taken off at least twice a day and the skin washed, ^ed 
and powdered before they are reapplied. 

Drformity of the limbs should be prevented; if a paralysed foot is lefl 
unsupported, it will droop and footdrop may be the result. 

Observation of the progress of the patient is made daily by the surgeon; but 
the nurse in attendance should t^e an intelligent interest in this, and note 
the findings at the first examination and the differences which appear later. 

As Steady indicated, the shock sustained and the bruising the cord 
will give rise to a flaccid or total paralysis; but as this passes off the lesion 
resulting from a fractured spine is that characteristic of an upper motor 
neurone lesion described on p. 407. The paralysed parts, from being 
limp and flaccid, become rigid and spastic; the tendon reflexes, lost at 
first, become bii^ and exaggerated; reflex movements occur, and the 
patient may be seen to draw hu legs up in response to any slight irritation. 
Spasm of the rigid irritated muscles may give rise to deformities due to the 
contraction of muscle, such as flexion and adduction of the hip, or con- 
traction of the knee in flexion, or of the tendon of Achilles givmg rise to 
footdrop. 

When any of these deformities are likely to occur the parts must be 
splinted in order to prevent contractures fiom arising. After several 
months, massage will usually be ordered to the affected parts and re- 
education wdll be encouraged in order to train the patient to use his 
muscles correctly as recovery gradually takes place. 

Unfortunately, some patients with fractured spine become bedridden 
for life; but every effort in re-education should be made in order to avoid 
such a calamity. In many cases the patient can be taught to balance and 
to walk, with ^e aid of either crutches or walking sticks. 

FRACTURE OF THE PELVIS 

The commonest cause of fracture of the pelvis is a crushing accident, 
and cither the true <w the false pelvis may be injured. Fractures of the true 
pelvis arc very likely to be complicated by injury to the Urethra, bladder 
and rectum. 

The patient will usually sustain a great deal of shock, his lower limbs 
being temporarily paralysed. There be considerable pain, and bruis- 
ing and swdling may be present, dqsending upon the type of injury 
which caused the finctiure. 



yRAGTURE OP THE PELVIS 605 

Treatment and nursing. The first requirement is to keep the patient 
absolutely still, as if the urethra and bladder are not already injured they 
easily xnay be by injudicious handling. The patient will be gently put into 
bed, to lie on a firm even surface. He should not be permitted to pass 
urine; if he is able to answer questions it would be useful to know when he 
la^t passed urine, before the accident; the nurse will then have some idea 
how much urine to expect. He should be cathcterized; if the patient is a 
female, and the nurse passes the catheter, she should use a rubber one and 
should notice whether any blood is obtained and, if this should come first, 
whether it is well mixed with the urine, or is obtained last. The quantity of 
mine should be noted. If any blood was present in the catheter specimen 
the patient should not be allowed to pass urine, but should be catheterized 
at regular intervals, the whole of the amount obtained each time being 
kept for the inspection of the surgecm. 

The area of the perineum, vagina and anus should be very carefully 
examined for signs of bruising or laceration. 

An X-ray examination of the pelvis will be carried out and the surgeon 
will decide whether the patient u to be put into a plaster of paris bed, or 
spica plaster of the hip, incorporating the trunk, or whether he is to be 
nursed flat on a firm bed, between sandbags with a firm calico binder 
applied around the pelvis in order to give some support. 

The care to be observed in nursing this patient is similar to that de- 
scribed in nursing a case of fracture of the spine. It is not allowable to roll 
or turn a patient with a fractured pelvis. — he should always be lifted; and 
the provision of a sectional mattress will be of great value when giving the 
bedpan or attending to the back. 


INJURIES TO JOINTS 

Sprains and dislocations are the conditions produced when a joint is 
the site of injury. 

A sprain is due to a forcible wrenching movement with sudden twisting 
of a joint which results in tearing the soft structures which surround it — 
ligaments, tendons and muscles. 

The lymptoms and signs are pain, swelling and difficulty in moving the 
joint. The treatment depends to some extent on the injury and also on the 
time which elapsed between the injury and the attendance of the patient 
for treatment. 

When a sprain is seen immediately after it has occurred, applications 
of cold water or ice will prevent effusion into the joint structures; this is 
then followed by a bandage, either cr6pe or elastoplast, firmly applied. 
The firm bandage will limit further swelling by preventing the effusion 
of fluid from the injured structures. This is of great value, as temporary 
and even pennanent thickening of a joint may follow if treatment in the 
early stages is neglected or unobtainable. 

If the injured joint is not seen for some time, and considerable swelling 
has occurred, the treatment is to apply heat in order to help absorption 
of the effusion which has collected around the joint, and this may be fol- 
lowed by gentle massage of the muscles above the injured area in order, 
by promoting the return of lymph and blood, .to help removal of the waste 
products. A firmly applied bandage should then be put on. In both in- 



6o6 INJURIES TO BONES AND JOINTS 

stances it is advisable to rest the joint until all pain has (disappeared, and 
even when movement is permitted the patient should be e^vised to kero 
the joint elevated whenever he can, in order to assist the return of lymph 
and venous blood from it. 

Dislocation. A dislocation is the displacement of two bones entering 
into the formation of a joint. Such an injury may be congenital, as in con- 
genital dislocation of the hip which may be unilateral or bilateral; or it 
may be pathological when the bone ends become seriously eroded by disease 
and can no longer remain in an adapted position, one with the other — 
this occurs in Paget’s disease and in tuberculous disease of joints. 

A traumatic dislocation is dealt with here ; it is the commonest type of 
dislocation, and is brought about by violence. The shoulder is most often 
dislocated by falling on the outstretched hand, as when falling down a 
flight of steps or off a bicycle; the jaw is also rather easily dislocated and 
dislocations of the elbow and ankle frequently complicate fractures of the 
bones in these situations. 

The signs and synptoms are those of injury — ^pain, swelling, bruising, loss 
of function and deformity. 

Treatment consists in reduction of the dislocation as soon as possible; the 
longer it is left, the greater will be the effusion and swelling, and the rigidity 
and thickening of the joint brought about by this will make the 
period of disability of function longer than it need be. Fixation of the joint 
is necessary for a variable time, but must be long enough to permit <rf repair 
of the capsule of the joint, which has been stretched, and possibly tom, 
by the force of tlie injury. Once this is established treatment is aimed at 
the restoration of function which should be as complete as possible. For this 
purpose the patient will be given massage; the joint will be passively 
moved and he will be encouraged to move it actively — gradually at first, 
and then within the whole range of movement possible. In cases where 
wasting is marked electrical stimulation may be used as an adjunct to 
massage. 



Chapter 40 

Operation Technique, including the Preparation for an 
Operation in a Private House. Examples of Anaesthesia 
and the Preparation of the Patient for Anaesthesia and 
for Operation, including Preparation of the Skin 

Preparation of hands — Theatre dress — Sterilization of instruments^ utensils and 
dressings — Lotions — Antiseptic powders and pastes — Sutures^ ligatures and surgical 
needles — Preparation for an operation in a private house — Use of anaesthetics: 
general^ locals regional^ splanchnic^ spinal and sacral — Use of based narcotics with 
notes on post-anaesthetic care — Preparation of the patient for operation^ including 

preparation of the skin 

T he vast subject of surgical technique can only receive an introduction 
in a book of this size, and the points given are those with which the 
nurse should be most familiar and will most likely have to deal. 
The antiseptic technique introduced into surgery by Lord Lister has under- 
gone many alterations and modifications up till the present day. He taught 
that organisms were destroyed by strong antiseptic substances which he 
used principally on the wound and dressings employed in order to destroy 
germs which had gained access to the wound. He made at the same time 
some attempt to prevent the access of organisms into the wound, and he 
was the first to teach surgeons to wash their hands before as well as after 
operating. 

It is difficult and probably unnecessary to differentiate between anti- 
septic and aseptic technique as employed today, the main difference lying 
in the fact that the old antiseptic methods aimed at destroying organisms 
which had reached the wound, whereas the present aseptic methods aim at 
preventing organisms from reaching the wound. As organisms may reach 
the wound from the patient’s skin, the hands of doctors and nurses, the 
expired air of those around the operating table, or the instruments, swabs 
and dressings used, the adequate sterilization of all articles in the vicinity 
of the wound is the principle involved in aseptic surgery. 

Neither the patient’s skin nor the hands of the surgeons or nurses can be 
rendered absolutely sterile, and the latter will therefore be covered by 
sterile rubber gloves. Instruments and swabs can be perfeedy sterilized, 
and this is why as far as possible the surgeon always handles the tissues 
of the wound with instruments and swabs rather than with his hands even 
though they are gloved, A good nurse assisting at the operation in handling 
instruments and swabs will use forceps; she will also hold suture and needle 
in forceps when threading needles. 

The preparation of the hands of surgeons and nurses is carried 
out as carefully as possible. Surgeons and theatre nurses should make a 
practice of protecting their hands from contamination by always handling 
contaminated or septic articles with forceps — they should never touch pus. 
Should their hands become contaminated they must wash them as soon as 

607 



6o8 OPERATION TECHNIQUE 

possible in water as hot as can be borne, using a nailbrush, soap and 
disinfectant, scrubbing the skin well, stretching the fingers and scrubbing 
the stretched skin between the fingers and knuckles, paying special atten- 
tion to the papillary spaces over the pads of the thumbs and fingers. The 
nails should be kept well trimmed and should be short enough for t^e 
nailbrush that is used to get between the nail and finger bed. Nailbrushes 
employed for the prraaration of hands before an operation should be 
boiled each morning for 20 minutes and placed in an antiseptic solution 
such as lysol i per cent., or perchloride of mercury 1 /2,ooo in which they 
will remain during the day. 

The hands of nurses working in an operating theatre or surgical ward, 
maternity unit or infectious diseases block, should be kept firee of rou§^ 
skin, they should be well washed and cared for at night, the nails being 
attended to and any tags of cuticle removed, and the hands should be 
anointed with a healing lotion in order to keep the skin in good condition 
and as smooth as possible. 

Immediate preparation of the hands. The preparation of the hands of sur- 
geons and nurses varies with the wishes of me surgeon. Having the arms 
bare to above the elbow the first procedure is to wash them under running 
water as hot as possible, for 5 minutes at least, using a sterilized nailbrush 
and a liquid soap, paying special attention to the folds and creases of the 
skin, stretching the fingers apart to get between them, scrubbing well over 
the joints of fingers and knuckles and scrubbing the pads of the thumbs 
and fingers and paying special attention to the nails. The hands are next 
treated by an antiseptic such as biniodide in spirit, i /500, perchloride of 
mercury 1/2,000, or alcohol 70 per cent. This lotion is rubbed into the 
skin with a swab, using several pieces of gauze and discarding each in turn. 
Some surgeons like the hands to be so^ed in the antiseptic solution for 
two or three minutes, the forearms being swilled with the lotion as the 
hands are kept in the solution. 

The skin of the hands and arms is now considered prepared, and great 
care must be taken not to touch any non-sterile article. The next step in 
the preparation is to put on a special theatre dress and rubber gloves. 


THEATRE DRESS (see fig. 207, p. 6og). 

It is usual to wear an apron of mackintosh similar in shape to a butcher’s 
apron. This is put on first. Some surgeons like the nurses to wear canvas 
boots over their shoes and stockings; these are fastened round the leg with 
tapes, puttee fitshion. 

Cap. The cap is worn so that all hair is covered, and that there may be 
no risk that hair might fall from the heads of those around the operating 
table on to the articles in the vicinity of the wound. The cap should be put 
on by an assistant, as it is practically impossible for anyone to put a cap 
on his own head without contaminating his hands. 

Mask. Hie ma^, which idiould also be put on by an assistant, is used 
to averid the danger of infection to the pafient by the fall of moist infective 
particles from the nose or mouth of those working in the vicinity of the 
operadng table on to the articles which will be used in and atwut the 
room. I^pkts of moisture are carried a certain distance from the nose 



6o9 



Fig. 207.— page 608. 

Nurse in Theatre Dress: Cap, Mask, 
Gown, Rubber Gloves and Canvas 
Covers over her Shoes. 


DD 



6io 




Fk;. 208 . — see page 617. 

Preparation of Gloves For Steam Sterilization, 

(i) The cuffs arc Folded back. (2) They are placed in a glove sac. 
(3) gauze packet of powder is placed in each glove sac. The 
gloves are packed in drums in sizes a.s shown. 



6ii 





CauZCRoLL. — 

raiiSKIII. 


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Dressinc Drum 




iuj. 209 . — sec paiff 620. 

Shows the contents of an Operation Drum and the Method of Stitching 
THE Abdominal Swabs f)R Dabs 

In tk operation drum (i) gauze roll. (2) (i-itich stitched dahs, h-inch stitched 
dabs (4) ,2-iiich stitched dabs, and (5) unstitched dabs i'or the skin 
T^e drcssmn drum contains ^A) white wool. (H) gauze. iC) gauze packing' and 


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615 




ARTICLES FOR SKIN 
PREPARATION 


Fig. 213 . — see page 633. 
Upper Shelf. Bottles containing 
methylated spirit, methylated ether 
and an antiseptic solution — three 
porringers — a preparation drum which 
contains sterile swabs, a sterile towel 
or pack for application to the pre- 
pared skin, and bandages. Forceps 
are provided to handle the swabs. 
l^owER Shelf. Towel to protect the 
bed and the articles needed for 
shaving the skin. 


Fig. 214. 

1 . Pair clippers. 

2. Safety razor. 

3. Method of holding an open 
razor. 





6i6 



Fig. 215. — see pages 649-651. 
The Upper Shelf contains a 
tray with instruments— scissors, 
artery forceps, dissecting for- 
ceps, sinus and dressing forceps, 
probe director and probes — 
also sterile dressings and towels, 
antiseptic swabs, sterile rubber 
tubing, measure, lotions, por- 
ringers and lotion thermometer 
and Cheatle’s forceps. 

The Lower Shelf contains 
bandages, safety pins and 
receivers. 



Fig. 2 1 6. — Articles required for Opening an Abscess. 

Lower Row (i). Reading from left to right: Scalpel, dissecting forceps (plain 
and toothed), Mayo’s curved dissecting scissors, several pairs of Spcncer-Wclls’s 
artery forceps, Volkmann’s spoon, probe director and probe, sinus forceps. 
Upper Row {2). Surgical needles and Hegar’s needle holder, drainage tubing 
(tubular and corrugated), silkworm gut, silk and catgut, small dissecting forcepw 
and stitch scisjiors. 


THEATRB DRESS 6 1 7 

and mouth in speakings and these are always a source of infection, more 
especially so when the speaker has a carious tooth, or a cold in the head. 

The mask or veil should be of a material equal to the thickness of five 
layers of surgical gauze, and some surgeons have them made of several 
thicknesses of butter muslin or a fairly thick cotton material. The upper 
part should reach the bridge of the nose and the lower part extend below 
the mouth and chin where it han^ in sacklike fashion, the ends being 
tucked in beneath the neckband of the overall. If the person wearing a 
mask wishes to cough or sneeze his head should be turned away from the 
operating table and from all articles in the vicinity of it. 

Gowns. The gown is put on next. A sterile drum is opened by an 
assistant and the person who is ‘scrubbed up’ takes a gown, which he finds 
folded up; holding it well out in front of him he unfolds it, taking care that 
it does not touch his own clothing or any other non-stcrile article. He then 
puts his arms into the sleeves of the gown and extending them in front of 
him slips it on. As the gown is sterile, he may touch the front of it and so 
help to get it into position. It is usually fastened behind by tapes on the 
neckband, and at the waist, but he must not touch these as they may 
dangle against his clothing behind and so become soiled. An assistant will 
fasten these tapes; she takes hold of the ends, being careful not to touch 
the sterile gown and tics them comfortably tight. 

Gloves. Gloves arc used as a protection; the impossibility of actually 
sterilizing the skin has been mentioned, so also has the necessity of pro- 
tecting the skin of those who are to assist at surgical dressings from contact 
with septic matter and pus. 

The gloves used for operation work should be thin rubber ones which 
will not interfere with the sense of touch; stouter ones may be used for the 
handling of surgical dressings. For preparation see fig. 208, p. 610. 

Gloves may be sterilized by boiling, in this case they will be wet, and 
placed ready in lotion; or they may be steam sterilized, being packed in 
drums, and in this case they are dry and ready prepared in powder, 

S acked up in pairs. Before applying dry gloves, the prepared hands should 
e dabbed dry with sterile talcum powder which is usually supplied ready 
in gauze packets. It is comparatively easy to put on dry rubber gloves 
(but see precautions mentioned below). Boiled gloves supplied wet require 
greater gare. In this case the gloves are loosely tied in pairs, having been 
transferred from a sterilizer of boiling water to a bowl of cool lotion, but 
the gloves may contain some very hot water, and therefore the nurse 
who transfers them ought to hold them inverted in forceps long enough 
for this water to run out, otherwise the unwary may be scalded. 

To put on the gloves. Take bold of the cuff and fill it with the lotion 
in which it lies. Holding the cuff with one hand insert the other hand 
into the glove, hold the glove fingers down over the pail or dish and not 
over the lotion bowl in which they were served. The hand will displace the 
lotion; having got the glove on raise the hand to allow the remaining 
lotion to drain out of the glove; this lotion should not be allowed to run 
over the surface of the gloved hand, as having been in contact with the 
skin of the hand it may be contaminated by staphylococci. When the 
glove is empty fold the cuff of the sleeve of the gown neatly about the wrist 
and bring the cuff of the glove up over it so that there is no space between 
glove and gown sleeve. 

BE 



6l8 OPERATION TECHNI(iUE 

PrecautioiiE in the use of gloves. Gloves should be handled as little 
as possible. As already mentioned water or lotion from the interior should 
be drained out and not allowed to run over the glove. If the fingers of the 
glove arc not properly on, they may not be handled with the skin of the 
bare hand but, when both gloves are on, they may be gently cased on the 
fingers; or a wet sterile swab may be employed to smootih the fingers dovra. 
If die ends of the fingers do not reach the ends of the gloves it is better to 
take the gloves off and put on another pair than to continue to wear them 
and so risk injury to the rubber. Gloves arc easily pricked with needles 
and injured by rough handling; a punctured glove should be removed at 
once and a fresh one put on. Care should be taken not to injure the cufi* in 
removing gloves. 

After use gloves should be washed in cold water, turned inside out and 
washed again, boiled for ten minutes, hung up inverted in order to drain, 
and finally dried by blotting with a soft cloth and inflated to inspect them 
for minute punctures. Small punctures may be mended^ but mended gloves should 
never be used for operation work though they may, with care, be employed for 
surgical ward dressings. 


STERILIZATION OF INSTRUMENTS, UTENSILS AND 

DRESSINGS 

Instruments used for operating work except sharp ones should be 
boiled for 20 minutes in a sterilizer with a closed lid in water containing 
I per cent, sodium bicarbonate. They are then placed in sterile dishes, 
either lying on a dry sterile towel, or in sterile water or some antiseptic 
lotion such as carbolic 1/80. 

Cutting instruments such as knives, scissors and needles have the edge 
blunted by boiling, and these are usually sterilized by placing them in 
pure lysol for 4 to 5 minutes and then in methylated spirit in order to 
remove the lysol which is injurious to the skin. A freshly sharpened knife 
is only used once; it is washed and boiled after use and then resharpened. 

If an instrument slips off the operating table and is required again, it 
must be washed, and boiled for 10 minutes, and be cooled, before it can 
be handed to the surgeon again. 

Rubber tubing is usually boiled for 20 minutes and then kept in carbolic 
lotion 1/60; any part removed from the jar which is not used should be 
boiled for 10 minutes before being replaced. 

After use. Instruments must be washed in cold water after use, and all 
crevices and joints scrubbed with a nailbrush in order to remove blood 
and debris. Hollow instruments, such as cannulae, should be flushed with 
water after washing. The instruments arc then boiled for 20 minutes 
before being put away. They are placed to drain on soft absorbent towels 
and polished with a soft dry cloth. Cannulae and hollow needles arc 
syringed through with methylated spirit and well shaken to free them 
from moisture. The stilcttc is then replaced and removed over and over 
again, drying it each time until it has ceased to receive moisture from 
contact with needle or cannula. This instrument is then placed on a warm 
surface, such as a radiator, to finish drying. Large hollow instruments, 
such as flushing curettes, usually have a little rangoon oil poured in to 
prevent rusting of the interior. Needles and scissors arc soaked in lysol 
and spirit after use. 



8TERILI2AT10N OP INSTRUMENTS 619 

Porringers, bowls, dishes, trays and receivers are all sterilized 
by boiling or by steam^ disinfection, and it is very important for the nurses 
to get us^ to hapdling these articles when sterile. It should never be per- 
missible to lift a bowl or similar article with the thumb inside as one might 
take hold of a kitchen utensil. If the bowl or porringer has a handle it 
can readily be removed by one hand, but otherwise unless it is very small 
it will need the use of both hands. Again, bowls do not remain sterile just 
because they have been boiled, and once a bowl has, for example, been 
placed to stand on a non-sterile surface the outside is contaminated; 
if the bowl is inverted on this surface, then the inside is contaminated. 

Care of syringes. A great many of the syringes used today are of the 
record type, which has a metal plunger and a glass barrel with metal 
ends. It is necessary to take a s^nge to pieces in order to sterilize it^ and after- 
wards it should be cooled in sterile lotion before assembling the parts 
again; and all parts should be quite cool because, glass cooling more 
quickly that! metal, if the syringe were assembled before the metal had 
cooled, the glass contracting on the more slowly contracting metal 
would crack. 

After using a syringe ^ it should be washed through in order to remove 
serum or any other substance containing coagulable protein; cold or 
tepid water should be used for this purpose. The syringe should then be 
taken to pieces and washed under running water. It should be shaken 
to dry it, or methylated spirit might be run through the syringe. When 
it is thoroughly dry it may be reassembled. The needle should be 
thoroughly dried by inserting, removing, drying and reinserting the 
stilette as often as necessary until no moisture remains on it. 

Dressings. Materials used for surgical dressings must be sterile and 
should readily absorb moisture in order that the discharge from the wound 
will rapidly be collected by the dressing. Gauze is better than cotton wool 
as the latter becomes sodden, but the gauze readily evaporates the 
moisture it collects and thus encourages drying. By this means serum or 
other discharge is conveyed away from the wound, permeating a large 
area of gauze it rapidly dries, so that collection of fluid over the surface of 
the wound, which would provide a good medium for the growth of 
organisms, is prevented. 

When the oozing of scrum is profuse and the dressing, including the 
cotton wool covering the gauze, and perhaps even the bandage is per- 
meated by it, it is important to cover the wet patch with dry sterile wool 
in order to prevent the entry of micro-organisms which will find the serum 
a suitable medium for their growth, and in the sodden wet dressing a rapid 
means of entry to the wound beneath. It is to prevent this from happening 
that operation wounds arc carefully watched for the oozing of serum. 

Materials used for surgical dressings, as those made of gauze and wool, 
gamgee tissue, and also such articles as jaconet bandages and safety pins 
may all be sterilized by steam disinfection. 

Dabs and swabs. Dabs or swabs for ward dressings are often made of 
cotton wool wrung out of an antiseptic solution such as carbolic 1/60 or 
perchloride of mercury 1/2,000. Sterile wool is used, placed in a sterile 
towel across a sterilized bowl, the wool being folded into the towel as in 
the preparation of a fomentation, the lotion poured over and the wool 
wrung out. The wet wool is then separated into flakes of the size desired, 



620 OPERATION TECHNI(JIJE 

and put into china or glais jars which have been prepared by washing in 
soap and water and rinsing with carbolic lotion. Similar swabs may be 
used for minor operation work, but as a rule sterilized gauze swabs arc 
employed at all operations. These are made of gauze folded in different 
ways according to the custom of the hospital and the wishes of the surgeon. 
As a rule the precaution is taken of having all raw edges folded inwards so 
that frayed strands of gauze cannot catch in the wound or be caught by 
the instruments used. Swabs used in abdominal surgery arc stitched to 
prevent this complication. Different sizes arc put up in bundles of six and 
twelve. The gauze is folded into six or twelve thicknesses, the margins 
being stitched. Gamgee tissue may alternatively be used. The stitching is 
carried across from comer to corner, as in mattressing, in order to keep 
the shape better. For preparations sec fig. 209, p. 6ii. 

Abdominal swabs may be plain or tap^, the latter having a length of 
tape sewn on one side or to one corner for use when the surgeon wishes 
to bury a swab deep in the abdominal cavity — the tape hanging out over 


RECORD OF SWABS 


Type 

Unstitched 3 dozen 

Abdominal 12 inch 6 


Used swabs* 

Unused 

i Total 

Illlllllli 11 

1 dozen 

36 

IIIIllIll 

and 3 

II 1 1 

2 

6 

mil 

7 

12 


Number 

available 


99 

6 .. 

4 dozen 

iiiiiiiiiiii 

1 1 1 1 1 1 1 1 1 1 1 1 

iiiiiiii 

i dozen 
and 4 

Pieces of 
roll 

gauze cut from 

2 

I 

i 


48 


2 


* Each stroke represents one used swab. 


Fio. 217 . — One Method of Recording the Swabs used at an Operation. 


the edge of the wound and being anchored by a pair of artery forceps. It is 
very necessary that this tape should be securely stitched on. A roll of gauze 
may be required by some surgeons for packing into the abdominal 
cavity; the surgeon will cut off the length he needs, tuck it in and secure 
the free end by forceps as in the case of the taped swabs. 

Some member of the nursing staff is usually in charge of abdominal 
swabs — it may be the theatre sister, theatre nurse or the ward sister. In 
hospital practice she is responsible to the surgeon and she should know 
how many swabs she has available at the beginning of the operation and 
check these numbers with her assistant. It is not sufficient to take it for 
granted that the specified niunbcr of swabs are contained in the different 
btmdles — each bundle used should be counted, the swabs being handled 



STERILIZATION OF INSTRUMENTS 62 1 

by Sterile forceps for this purpose. The number available at the commence- 
ment of the operation ought to be written on the slate provided. 

The sister in charge of swabs should follow the movements of the surgeon 
and notice where he places them, the number of taped swabs and gauze 
packs he may insert into the wound. As soiled swabs are dropped on to the 
floor or into a pail, the assistant with a pair of forceps — which need not be 
sterile — picks them up and arranges them in bundles on a towel placed 
on the floor beside the swab table. When six or twelve have been used she 
catches the eye of the sister in charge, who watches her count them and 
place them in a bundle; taped swabs are similarly dealt with. All used 
abdominal swabs must remain in view until the operation is over. Before 
the surgeon begins to close the abdominzd cavity he will usually ask the 
sister if the swabs are correct; she must be prepared to answer this ques- 
tion, and should one be missing the surgeon will search for it before he 
proceeds further. The swabs should again be checked when the operation 
is finished and the towels may then be removed from the area of the 
operating table. 

LOTIONS 

Various lotions are used in surgery, each surgeon having his own par- 
ticular choice in the matter. Some of the common ones in use include the 
following : 

Water, boiled for 20 minutes, is used by some surgeons for rinsing the 
gloved hands during an operation and for the immersion of instruments 
after they have been sterilized. 

Norma] saline solution o-g per cent, sodium chloride dissolved in 
sterile water is used to moisten swabs for use on wounds and for irrigation 
of cavities and by some surgeons for swilling the gloved hands during 
operation. 

Boracic lotion is a saturated solution which contains 5 per cent, of boric 
acid in sterile water. The lotion is made with boiling water in order to 
obtain saturation and it is then allowed to cool before use. It is very 
slightly antiseptic and is used in strength 2^ per cent, instead of saline, 
but it is more irritating to the tissues and to the lining of cavities. 

A weak solution of one of the aniline dyes is a vefy favourite anti- 
septic lotion today. In addition to its antiseptic properties most of those 
solutions possess the power of stimulating the healing of wounds and 
some — particularly flavine — are moderately powerful styptics. Flavine is 
used in the strength of i /i ,000. Others include scarlet red which is employed 
as a stimulating dressing to wounds; brilliant green and methyl violet are used 
for their antiseptic properties in the preparation of the skin for operation. 

Peroxide of hydrogen is prepared in strengths described as 5, 10 or 
20 volumes. This indicates that the solution contains so many volumes 
of available oxygen. It is valuable in treating septic wounds and cavities, 
and is also a valuable styptic. It should be mixed with warm water as hot 
water lessens its usefulness. It always froths up when in contact with 
decomposable matter which is not necessarily septic or containing pus. 

Alcohol is a most efficient disinfectant. For the sterilization of sharp 
instruments it is used as recited spirit, which contains 95 per cent, alcohol. 



633 OPERATION TBCHNIQ,UB 

During this present war spirit is difficult to obtain, and a st^ution of 
phenyl-mercurie^nitraU 1/5,000, containing 1 per cent, borax, in water, is 
alternatively used. It is considered efficient for the sterilization of instru- 
ments, and the added borax helps to prevent the instruments rusting. 

Iodine is used as liniment of iodine which is a 10 per cent, soludon— 
formerly known as dneture — for paindng on the skm and preparing it 
before operadon and also in repeated coats as a counterirntant. To be 
effeedve the skin should be dry before the iodine is applied, and in order 
to avoid producing blisters the applicadon should not be covered until 
it is dry. 

Formalin. A i per cent, solution is used for bathing wounds and as a 
lodon in preparing the hands before operation. It is, however, not very 
much used for these purposes but has by long use become invaluable for 
spraying the walls of rooms which have to be disinfected, and in solid 
form it is udlized for the produedon of vapour in the disinfection of such 
rooms and also in the sterilization of gum elastic and composition cathe- 
ters and of certain surgical instruments and appliances. 

Condy’s fluid (permanganate of potash) is a very favourite household 
disinfectant for sinks, drains, &c., the crystals being dissolved in water 
until a pale purple colour is produced. The soludon acts as a deodorant 
and also gives off oxygen; when in contact with decomposable matter it 
rapidly loses its antiseptic properties and then the colour of the Liquid 
changes to a dirty brown. A weak solution, which may be indicated either 
by producing a very pale mixture, or by measuring it to produce a solution 
of 1/5,000 in strength, is used as a mouth-wash and for gastric, bladder and 
rect^ irrigation, and for vaginal douches. 

The phenol group are derived from coal tar by processes of distillation, 
and the one mainly in use is carbolic, or phenol. It is highly poisonous and 
corrosive in action. Pure carbolic is sometimes used by surgeons to touch up 
septic wounds or the stump of the appendix. A strong solution, i/io ni 
spirit, is occasionally used to sterilize sharp instruments by immersion for 
1 o minutes; instruments so treated must be removed from the solution by 
forceps and washed in sterile water in order to remove the carbolic before 
they can be used. 

Carbolic i /20 or i /40 is used as a stock solution in which to keep boiled 
rubber tubing and silkworm gut, &c. This also is the strength in which 
this lotion is used for disinfecting discharges and excreta from typhoid 
fever cases and others; and also for the disiiffcction of infected utensils and 
clothing which should be soaked in it for two hours. A solution of i /60 is 
used as a lotion for disinfecting hands, a preparation of 1/80 or i /too for 
mouth-washes and gargles. 

Other disinfectants of the phenol group include izal, cyllin, Jeyes’s fluid and 
cresol and lysol — the two last prepared with liquid soap and therefore, by 
reason of their soapy nature, useful for cleansing purposes. They are 
generally considered more valuable disinfectants tiian carbolic and less 

E oisonous. Pure lysol is used for the sterilization of sharp instruments. 

ysol in the strength of 1 drachm to the pint is used for vaginal douches 
and as a lotion for bathing septic wounds. A stronger preparation, usually 
a I per cent, solution, is used for cleansing soiled ward utensils. 



UJTIONS 623 

Picrk acid is obtained by mixing phenol and nitric add. It is used as a a 
per cent, preparation in the treatment of burns and as a 3 per cent, prepara- 
tion in spirit for cleansing the skin before operation. 

Chlorine group. Eusol, Dakin's solution, chloramine-T and Milton arc 
examples of this preparation, Eupad is a mixture of bleaching powder and 
boracic acid in equal parts, and Eusol is a solution of these powders which 
is vised as a wet dressing or for the constant irrigation of wounds. 

Dakin's solution is a modification of eusol, and is a hypertonic solution 
employed in the Carrel-Daldn irrigation treatment of septic wounds. It 
was extensively used during the war of 1914-18. Being hypertonic, it en- 
courages the free flow of lymph from the wound and results in the removal 
of dead tissue. 

Milton (Electrolytic sodium hypochlorite) is used in from i per cent, to 
20 per cent, solutions as treatment of burns and wounds. The use of 
hypochlorites' is considered to dissolve and remove tissue debris. (Sec 
treatment of burns, p. 576.) 

Mercury group. The mercury group contains perchloride, biniodide and 
ofyiyanide of merewry. 

Perchloride is also described as corrosive sublimate, and is the one most 
universally used. All mercurial preparations are unsuitable for the pre- 
paration of instruments as they discolour them. They may, however, be 
used for the sterilization of rubber composition and gum elastic catheters, 
in the strength of 1/1,000. Perchloride of mercury is most commonly 
employed as a hand lotion in the strength of 1/2,000; it is used for vaginal 
douches as i /4,ooo but the precaution is usually taken of following such a 
douche with one of sterile water to obviate any possibility of mercurial 
poisoning. A solution of 1/10,000 is used for bathing the eyes, but some 
surgeons prefer to use oxycyanide for this purpose as it is less irritating. 

Biniodide of mercury is slightly less poisonous than perchloride and is used 
for similar purposes. A solution of biniodide 1/500 in spirit is used by some 
surgeons in the preparation of their hands before operation. 

Silver salts. Silver nitrate is the most powerful but it is rarely employed. 
It will occasionally be used for irrigation of the bladder and rectum in 
solutions of 1/1,000 to 1/5,000. 

Protargol and argyrol are used as antiseptics in the treatment of infective 
conditions of delicate mucous membranes — as of the eyes in purulent 
conjunctivitis — in ^-i per cent, solution, and in the treatment of acute 
cervicitis in 1-2 per cent, solution. 

Chlorocresol and Chloroxylenol. Some newer types of antiseptics 
are based on the chlorinated derivatives of the higher phenols, i.e. 
chlorocresol and chloroxylenol. These are powerful bactericides of rela- 
tively low toxicity. Chlorocresol 0-05 per cent, is approximately equal to 
0'5 per cent, phenol as a germicidal agent. 

Chlorocresol is used chiefly in the preservation of pharmaceutical pre- 
parations, such as those solutions which are put up in rubber-capped 
bottles for hypodermic injection. 

Chloror^lenol is more powerful than chlorocresol, but it is less soluble in 
water and is usually exhibited in a saponaceous base, frequently mixed 
with aromatic and antiseptic oils. Liquor Chlororylenolis N.W.F. meaning 
National War Formulary solution, and preparations such as Dettoi, 



624 OPERA-nON TECHNIQUE 

Kilsol, Zant, and Zenol are examples of solutions of chloroxylenol. These 
solutions may be safely applied to the skin, for a very short time, undi- 
luted; a 5 or I o per cent, solution may be employed for swabbing the skin 
around a wound and solutions of a drachm to the pint may be used for 
irrigation of the bladder, vamnal douching, &c. It is claimed that these 
preparations of chloroxylenol are non-irritating to the majority of skins. 

ANTISEPTIC POWDERS AND PASTES 

Iodoform powder liberates iodine when in contact with warmth 
and moisture, as when it is applied to the surface of wounds, and is very 
largely used in the treatment of septic wounds and tuberculous ulcers. 

Bismuth, iodoform and parafiBin paste (bipp) is a paste which may 
be applied to surfaces, packed into wounds or injected into sinuses. 

Aristol is a proprietary preparation containing iodoform and is used 
for dusting wounds and ulcerated surfaces. It promotes healing. 

Eupad is a preparation of eusol, and is a mixture of bleaching powder 
and boracic. It is sprinkled on to wounds instead of the solution. 

Boracic powder, boracic and starch, or boracic, zinc and starch arc all 
used as dusting powders, mostly for their drying effect and also for their 
slightly antiseptic properties. 

Sulphathiazoie powder is either sprayed on to or packed into wounds 
in a prescribed dose of i to 2 grammes. 

SUTURES, LIGATURES, AND SURGICAL NEEDLES 
(See fig. 220, p. 681.) 

Materials used for sutures and ligatures are divided into absorbable 
and non-absorbable ones. 

The most commonly used absorbable substance is catgut which is pre- 
pared by removal of the fat from the intestines of sheep by scraping and 
treatment in a preparation of sulphuric acid, and rendered sterile by 
means of soaking in iodine. It is then put up in different lengths and 
graded into different thicknesses ready for use. 

Catgut may be ‘plain,’ when prepared as just described, in which case 
it is absorbed in about 7 days when buried in the tissues; or, it may be 
subjected to a hardening process by soaking in chromic acid for a certain 
time; it is then said to be ‘chromicized’ and, according to the degree of 
hardening produced, may last as long as 10, 20 or 30 days before it is 
absorbed. 

Kangaroo tendon is also chromicized ; it is very strong and hard and 
lasts from 6 to 8 weeks. 

The non-absorbable materials include silk and linen thread used for 
buried tissues and silkworm gut and horsehair for suturing the skin. Coats’s 
cotton, no. 24 and 40, has recently been recommended to replace catgut. 
These are all prepared by boiling. 

SUver voire is used for maintaining parts of bone in apposition. 

Michel’s clips, which are used for the dun, are spik^ clips applied by 
means of a special pair of forceps, and as a rule, whra these are employed, 
tension sutures are inserted. Michel’s clips are removed after 5 days, as if 



SUTURES, LIGATURES, AND SURGICAL NEEDLES 625 

left longer they result in unpleasing marks on the skin, tension sutures are 
remov^ several days later. 

Stitches used in surgery. These may be approximation sutures when 
used to keep the edges of the wound together, or tension sutures when 
intended to take the strain off the skin sutures. These are passed through 
the deeper structures. All surgeons do not use them, some claiming that 
they stitch up each individual tissue fibre so completely that tension 
sutures would be redundant. 

Some of the commoner stitches used include a continuous one, which may 
be simple oversewing well spaced or a form of blanket stitch. An interrupted 
suture is one in which each stitch is tied separately, a reef knot being used. 
Mattress stitch is the form used when tension sutures are inserted. 

To remove stitches. When interrupted sutures have to be removed, take 
hold of the knot with a pair of directing forceps and pull gendy until a 
portion of the buried stitch is visible, cut this with sharp pointed scissors, 
then pull the stitch out by means of the dissecting forceps with which it is 
being held. Pull from the side of the wound opposite to that on which the 
stitch has been cut and, in this way, dragging any part of the dry suture 
material which has lain on the surface of the wound through the stitch 
puncture will be avoided. 

Surgical needles. These are of various shapes, sizes and types. Those 
most commonly used are : 

Half-circle. Curved. Straight. 

Any of these shapes may be : 

Round bodied, non-cutting needles, used for intestine; 

Cutting needles with a 3-sided cutting edge and a sharp point; 

Flat or Hagedom's needles, with flat bodies and a bevelled edge which 

is fairly sharp (see fig. 220). 

PREPARATION FOR AN OPERATION IN A PRIVATE HOUSE 

The amount of preparation depends upon the time available, the first 
and most important point being the avoidance of much moving of articles 
in the room with its consequent disturbance of dust — unless over 24 hours 
can be allowed for this to settle. The second point is to choose a room 
sufficiently large and if possible with a northeast aspect and a large win- 
dow; a room near a lavatory or bathroom is preferable and if there is a 
fireplace in the room it can usually be employed for the burning of soiled 
dressings, &c. Some form of heat in the room must be provided. 

Preparation when a reasonable amount o| time is available — 
say 2-3 days. Take down curtains, windowblinds and pictures, remove 
carpets, rugs and ornaments, have all unwanted furniture carried out of 
the room; then cover the remaining furniture and sweep the ceiling and 
walls, windowframes, doorposts and all light fittings. As far as possible use 
damp brooms for sweeping and damp dusters for dusting. Open all doors 
and windows and leave the room for 1 2 hours. Then waish the floor with 
disinfectant and with a cloth moistened with disinfectant wipe doors and 
windowpanes and all woodwork, such as the wainscoting, and treat any 



6a6 OPERATION TBCRNI<^UE 

heavy furniture that is being kept in the room in the same way. Then close 
and clean the windows and, if the room is overlooked, cover the glass 
with old muslin or old lace curtains stretched across the frame and sectired 
with drawing pins. 

Articles required. The furniture and other articles which might be pro- 
vided in this room in which the operation is to be performed include a 
table suitable for the operation unless the nurse knows that the surgeon 
will bring his own. A small table, and a stool or high chair should be 
provided for the anaesthetist. Three or four small tables will be required 
for the surgeon’s instruments, dressings and lotions, &c. Some means must 
be provid^ for boiling instruments; the nurse may have to provide a 
suitable utensil for this purpose, in which case she might choose a fish 
kettle; and she should have considered where this or other utensil can be 
boiled in case the surgeon does not bring his own sterilizer. A washstand 
with two basins, if possible two nailbrushes, ready sterilized, soap-dish and 
bowl for lotion, should be provided, unless the room contains hot and 
cold running water. Enamel or delf jum which can be sterilized by flaming 
them with methylated spirit should be prepared; these will be used to 
contain quantities of cooled boiled water, and hot boiling water ready for 
making lotions, &c. One or two pails will be required for used lotion 
and either a small bath or several shallow enamel basins in which soiled 
dressings and used instruments can be placed. A number of basins and 
shallow dishes which can be sterilized by flaming if required should be at 
hand on which the surgeon might like to place his instruments and towek. 

A number of clean blankets, sheets and towels and any mackintoshes 
the house can muster should be collected, also some old dustsheets to pro- 
tect the floor. Hot water bottles should be in readiness to be filled at the 
last minute and a change of clothing for the patient ought to be at hand in 
case what he is wearing during the operation becomes soiled. 

The nurse should have ready any articles for which she is responsible, 
including some form of antiseptic, normal saline, bandages and safety pins, 
razors and scissors. As a rule the surgeon will bring everything he requires 
— instruments, gowns, sterile towels and mackintoshes, swabs, gloves and 
dressings. 

Emergency preparation. A nurse may be sent to a private house to 
make the necessary preparations an hour or two before the surgeon is 
expected. In this case her procedure would be very different. The room 
should be chosen as rapidly as possible, bearing in mind the points above 
mentioned. It is inadvisable to move anything excepting so far as to clear 
the centre of the room to make space for the operating table, and tables 
for instruments and lotions, &c., together with a table and chair for the 
anaesthetist. The articles moved to the sides are to be covered up with 
sheets or dustsheets; the carpet should be carefully covered with (bunped 
dustsheets in order to prevent dust from rising as the surgeon and others 
walk about. The windows should be closed and the curtains drawn gently 
to one side in order to prevent the displacement of dust, the blinds rolled 
up and if necessary some clean window muslin pinned across the glass. 
Dusting should be done with damp dusters. There should be an adequate 
supply of boiled water, and useful utensils should be collected and pre- 
pared. 



THE USB OF ANAESTHETICS 


627 


THE USE OF ANAESTHETICS, AND THE CARE OF PATIENTS TO 
WHOM THESE HAVE BEEN ADMINISTERED 

Before considering the care of a patient who has had an anaesthetic it is 
essential that the nurse should understand certain terms used in the 
administration of these. 

General anaesthetics. For the induction of general anaesthesia, 
ether, chloroform, nitrous oxide gas, and gas and oxygen are amongst the 
drugs most commonly employed. The mode of administration varies — the 
open method indicates that the drug is dropped on to material stretched 
across a mask, such as Bellamy-Gardner’s. The closed method means that 
the patient breathes in and out of a closed bag (see fig. 210, p. 612). 

Stages of Anaesthesia. The degree of general anaesthesia which may 
be produced has, for convenience, been divided into four stages, although 
the margins which divide these stages are never very clearly defined. 

First stage. This lasts from the commencement of induction until volun- 
tary control is lost. 

Second stage. Voluntary control is lost but the patient may continue to 
struggle involuntarily, and some of the reflexes are still present. 

Third stage. This produces entire relaxation. It is described as full 
surgical anaesthesia. It is during this stage that operations are performed. 
The breathing is deep and regular, the conjunctival reflex is lost and the 
comeal reflex sluggish. 

The fourth stage is that of overdose. 

Local anaesthesia. This might more correctly be termed analgesia, as 
it produces loss of sensation to pain without loss of consciousness. Local 
anaesthesia may be produced in different ways (see fig. 21 1, p. 613). 

(1) application of a drug to a mucous .surface. This method is used for 
operations on the nose, pharynx and larynx. In operations on the eye a 
number of drops of 4 per cent, cocaine are instilled into the conjunctival 
sac. 

(2) By injection into the tissues. This is termed infiltration anaesthesia, and 
paralyses the nerve endings in the part into which the drug is passed. 

(3) By injection into the vicinity of a large nerve trunk, or into the nei-ve trunk 
itseff (see also regional anaesthesia). 

(4) By freezing. This is not very commonly employed. An ethyl chloride 
spray is used, the substance being directed on to the skin until, by the 
extremely rapid evaporation, the part is frozen hard. This takes place in a 
few seconds and only lasts for a few seconds and is therefore only available 
for operations of a very short duration, such as incising a septic finger. 
Freezing makes the tissues tough and difficult to incise. 

Regional anaesthesia. This method of producing anaesthesia is an 
attempt to block all the afferent impulses passing from the operation area 
to the central nervous system. It may be carried out in two ways, cither by 
injecting the drug into the area around a large nerve trunk— ^oraseura/ — 
or, more rarely, and very carefully, into the nerve trunk — intraneural. 

Splanchnic anaesthesia. In this method, analgesia of the abdominal 
organs is obtained by regional anaesthesia of the coeliac plexus, which is 
the region where most of the sympathetic nerve trunks supplying the 
abdominal organs lie close together. 



628 OPBRATTON TECHNiqUB 

Spinal anaesthesia. This is a variety of regional anaesthesia em- 
ployed to effect loss of sensation in the lower limbs. The needle is inserted 
into the sub-arachnoid space between the fourth and fifth linnbar verte- 
brae; cerebrospinal fluid is allowed to run out and, when flowing freely, 
the necessary drug is introduced by means of a 10 c.c. syringe (see fig. 212, 
p. 614). 

Post-operative care. Nurses are sometimes worried as to the position in 
which a patient should be nursed after a spinal anaesthetic. The position 
he lies in whilst the anaesthetic is performed and during the operation 
depends entirely on whether the solution employed is denser uian the 
cerebrospinal fluid as is stovaine, and some solutions of percaine, or 
whether it is less dense, as arc the weaker solutions of percaine. This 
difficulty is dealt with by surgeon and anaesthetist; but, as the effect of the 
anaesthetic will be abating when the patient returns to bed, the position 
in which he is nursed does not depend upon the anaesthetic factor, 
though, since the drugs used may result in serious lowering of blood pres- 
sure, it is inadvisable to sit a patient up for fear of collapse; and it is for 
this reason that the foot of the bed is elevated on blocks for several hours 
after the spinal anaesthetic has been administered. 

Sacral anaesthesia. This is similar to spinal anaesthesia and is simi- 
larly administered. It is used for operations on the perineum and its sur- 
rounding parts. The needle is introduced into the lower part of the spinal 
canal. 

Basal narcotics. Paraldehyde was the drug first employed in this 
capacity. It was given in normal saline and administered per rectum. One 
drachm of paraldehyde was ordered for each stone of body weight. It was 
given threequarters of an hour before the operation. As a basal narcotic it 
was found satisfactory, but it had the disadvantage of being excreted by 
the alimentary tract and produced a nasty taste. 

The drugs most commonly employed as based narcotics today are 
described as barbiturates. They arc derived from the veronal group. Some 
fairly common examples include sodium amytal, avertin, evipan, nem- 
butal, pernocton and pcntothal. These drugs are usually employed as 
adjuncts to general anaesthesia. In the majority of instances the degree of 
anaesthesia produced by them is not sufficiently deep to allow a cutting 
operation to be performed. 

Advantages. The tremendous value of basal narcotics lies in the fact that 
the psychic trauma which a patient sustains when an anaesthetic is given 
by the inhalation method is prevented. The patient goes to sleep in his own 
bed, on the stretcher by which he will be quietly moved to the operating 
theatre. After the operation he sleeps a fairly considerable time, and when 
he wakens has no recollection of unpleasant happenings. 

The drugs used may be administered by intravenous or subcutaneous 
injection, by the rectum or by the mouth. As described in the preparation 
for a local anaesthetic, the patient is prepared for the operating theatre 
beforehand, so that he can lie totally undisturbed once the drug hM been 
administer^. This is particularly important in these cases, as movonent 
or excitement after the administration of a basal narcotic may lead to the 
patient’s becoming exceedingly restless instead of going quietly to sleep. 

Administration of avertin. The dose of avertin is carefully calculated to 
correspond with the age and weight of the patient and his general condi- 



THE USE OF ANAESTHETICS 639. 

tion. Avertin is administered in a 3*5 per cent, solution in distilled water. 
As a rule a small quantity is tested by the addition of congo red, and if any 
trace of blue colour appears the solution must be discarded. The patient, 
having been got ready, is placed in the left lateral position and, using a 
catheter and funnel apparatus, about half the fluid prepared is slowly 
poured in, the catheter not being removed but the tube clamped and the 
patient carefully watched for about 10 minutes. If the patient is still con- 
scious the remainder of the fluid is administered and the tube removed. A 
pad of wool should be placed over the anal region in case any fluid returns 
when complete relaxation of the sphincter takes place, but as a rule 
avertin is rapidly absorbed. If possible, the patient should be kept in the 
left lateral position during his transfer to the theatre. The maximum 
effect of avertin occius about half an hour after administration; when 
given in conjunction with an inhalation anaesthetic, this is then com- 
menced so that the operation can be performed by the time the mzudmum 
effect is due. Avertin can also be given through a colostomy woimd, and 
in this case the absorption is more rapid. 

PentotkeU, pernacton and evipan are administered by the intravenous method. 
The general preparation is as usual. A tourniquet is applied to the arm to 
obstruct the venous circulation and render the selected vein prominent; 
injection of the drug is commenced, but there is no definite rule as to the 
amount required, this varying with individual patients and being usually 
determined at the time of administration by the observations of an ex- 
perienced anaesthetist of the effect on the patient. As a rule the fluid is 
allowed to run in at about the rate of one drop per second — a nurse stand- 
ing at the bedside steadies the patient’s arm and releases the tourniquet 
when required. 

Nembutal may be given by the intravenous route or by mouth. In the 
latter case it is given in capsule form, two being administered about an 
hour to an hour and a half before the operation and repeated 20 minutes 
beforehand if the patient is not asleep. Sodium amytal and soneryl are aho 
given by mouth. 

Intravenous anaesthesia is usually combined with oxygen or gas and 
oxygen. 

Post -anaesthetic care. The care of patients after the use of basal 
narcotics calls for a high degree of intelligent nursing observation. Every 
nurse who is to be entrusted with the care of a patient coming round after the 
use of these drugs should realize the difficulties which accompany their use- 
fulness. The patient’s bedside should not be left — ^for the following reasons: 

The first and probably the most important point is that these patients 
manifest a very marked degree of muscular relaxation, in which the 
muscles of respiration participate. The breathing may become too shallow 
to be effective, and the patient will get gradually pale and grey and cold 
and is in imminent danger of severe and serious collapse which may 
terminate in a fatal syncope. The treatment undertaken to deepen respira- 
tion is the administration of carbon dioxide 7 per cent, in oxygen. Many 
anaesthetists make a practice of administering this combination to patients 
before they leave the operating theatre in order to stimulate breathing, 
and the nurse in charge should note the effect of this administration ai^ 
be prepared to repeat it if she sees that the depth and rate of respiration 
are diminiahing. 



630 OPERATION TIOHNI{2l^ 

Another imporUnt point is patients who have had basal narcotic 
drugs do not completely recovw consciousness for a number of hours and, 
although they may have what appear to be Ii^d intervals, they do not 
remember anything that has happened. During these hours they may 
become very restless, fiequendy attempting to get out of bed. In appar« 
endy lucid intervals a padent may automadcally perform moveinents 
and have no conscious knowledge of his action. For example, an inex* 
perienced nurse might leave a padent who is apparendy conscious with a 
feeder of water, fi-om which he may drink, having first apparendy grasped 
the feeder eagerly so that the unwary nurse imagines he is quite sensible. 
She may therefore think he will drink, and place the feeder on his bedside 
locker. Not so! It is much more likely that he has not the least idea of what 
he is doing and having satisfied his thirst his grasp relaxes and the water is 
empded on to the b^. 

In some instances resdessness is prolonged and marked, requiring the 
constant and padent attendance of a nurse at the bedside, gendy restrain* 
ing the patient’s vigorous movements. A nurse should not confuse the 
resdessness which may occur during unconsciousness with restlessness due 
to pain on the patient’s coming round from the anaesthetic. After the use 
of basal narcotics it is inadvisable for a patient to be given morphia until 
he is fully round as the effects of both drugs — the basal narcotic and the 
morphia — acting together may cause serious respiratory and cardiac 
failure. It is improbable, however, that a doctor would order morphia 
without having satisfied himself, by seeing the patient, that he is com- 
pletely round. t 

THE PREPARATION OF A PATIENT FOR A GENERAL 
ANAESTHETIC AND OPERATION 

An operation is a very serious matter; it is an ordeal which may be 
described as an injury to the general physical wellbeing of the patient. 
In many cases the ultimate result of an operation will be an improvement 
in healdi; nevertheless at the moment it is done it constitutes an injury. 
It exposes a patient to the condition of surgical shock which is largely 
brought about by repeated painful stimuli reaching the central nervous 
system. The patient may be anaesthetized and therefore does not feel 
this pain, but the stimuli produce their ill effects, and these are shown in 
the lowered blood pressure and the interference with the depth of respira- 
tion culminating in surgical shock. 

The patient who is returned to the ward firom an operating theatre is 
not just an operation case but a person who has been seriously hurt, and 
nurses should try to realize the injury sustained by cutting the skin and 
tissues beneath it, and, however gentle it be, the constant manipulation of 
delicate structures with knife, forceps and fingers, knowing that each 
injury which wotdd catisc pain in a conscious person is productive of 
almost similar exhaustion of the central nervous system in an unconscious 
person. The administration of a general anaesthetic helps a little; some 
forms of anaesthesia, such as local and regional, help considerably to pre- 
vent painful impressions from passing ^ong the afferent nerves, with 
resultant injury to the central nervous system. The description of the 
various terms given on pp. 627-8 are intended to hdp nurses to know the 
value of the choice of the different forms of anaesthetization available. 



THE PREPAXATIOH OF A PATIENT 63 1 

The handling of certain tissues, particularly all nerve matter, serous 
membranes and the perineal region, results in a very rapid fall of blood 
pressure and consequently gives rise to a more serious condition of shock 
than docs the handling of other types of tissue 

General preparation. The condition of the teeth, tonsils, heart and 
lungs and of renal efficiency will be investigated, and any treatment 
required will be performed some weeks beforehand. The patient should 
be made familiar with the conditions under which he is to live in the days 
immediately following his operation. In some instances it may be neces- 
sary for the patient to have complete rest in bed; in others it will be suffi- 
cient if he lives in the ward, getting used to sleeping in a ward with others, 
and becoming accustomed to the unusual sounds and so on. His tempera- 
ture should be taken morning and evening so that any deviation can be 
noticed. He should have a d£^y bath, his urine should be tested, particu- 
larly for the presence of acetone, sugar, and albumin, and his bowels 
should be remlated if necessary by the use of an aperient to which he is 
accustomed. In some instances a special diet may be required, to improve 
the condition of the stomach, and in practically all instances fluids should 
be given freely. A woman should not be operated upon either imme- 
diately before or during her menstrual period. 

The prtvention of fear is highly important and it is avoided to a great 
extent by having the patient in hospital two days beforehand. Fear should 
not be mentioned, and the nurse who says ‘Don’t be frightened, you will 
be all right’, is no psychologist. True peace of mind is induced by the 
confident, businesslike way in which surgeons, sisters and nurses perform 
their work in the preparation of the patient for operation, and such con- 
fidence can be drawn from the knowledge that they have successfully 
done the same for many others that the patient naturally comes to antici- 
pate the same success in his own case. This attitude of complete confidence 
IS conveyed to the patient by manner and by action rather than by words. 
If a patient asks questions about his operation he should be openly but 
carefully, though not guardedly, answered. 

More immediate preparation. During the two days of waiting a 
comparatively light diet is usually given; the bowels being regulated by a 
dose of a mild aperient 48 hours before the date of operation, thus leaving 
the night before operation free of anxiety with the possibility of obtaining 
restful sleep. It is essential for the patient to have a good night’s sleep, and 
to ensure this some surgeons order a sedative. 

The last meal should consist of bovril and toast, or tea and toast, and if 
the operation is at ten o’clock in the morning this may be given at 6 or 7 
a.m. If the operation is in the afternoon this small meal may be given at 
n a.m. 

Some surgeons give an alkali such as sodium bicarbonate and plenty of 
fluid with glucose several days beforehand in order to prevent the possi- 
bility of acidosis; and especially in the preparation for operations on the 
alimentary tract, when food may have to be restricted for some days after 
the operation. 

Immediate preparation. Half an hour before the anaesthetic is 
administered an injection of morphia or atropine or a combination of both 
is usually givm. The dose of morphia may be i/6th to ^ of a grain, and 



632 OPERATION TEOHNIQUE 

the dose of atropine i /120th or i/iooth. Morphia allays the patient’s 
fears, and renders him drowsy so that he does not think or worry and is 
therefore less predisposed to shock. Atropine inhibits the secretions and 
limits the amount of mucus present in the respiratory tract — which is 
specially stimulated by ether— during the anaesthetic, and so helps to 
avoid the possibility of respiratory complications later; in addition, it 
makes the work of the anaesthetist easier. 

Before this injection is given the patient should be made ready in the 
clothing in which he is to be taken to the theatre, and as chilling must be 
avoided tliis usually consists of a woollen Jacket and leggings in addition 
to the nightshirt or nightdress — ^the latter should be cotton and of a shape 
that can easily be rolled up over the trunk when the abdomen is to be 
operated upon. The bladder should be emptied, but in operations on the 
lower part of the abdomen, particularly when a mid-line incision is to be 
made, a catheter should be prepared as it may be considered advisable to 
empty the bladder nearer the time of operation. A very large amount of 
urine may be secreted in a short time under conditions of fear such as a 
patient is to some degree experiencing in spite of all effort made to the 
contrary. Some surgeons like the patient to be catheterized and the 
catheter spigoted and left in the bladder so that the bladder may be 
emptied easily immediately before the first incision is made. 

The patient’s hair should be suitably arranged — in some instances it 
should be covered by a bandage or special cap; long hair is best plaited 
on each side of the head, all jewellery except tne wedding ring should be 
removed. At the last moment, as the patient is placed on the trolley or 
wagon on which he is to be conveyed to the theatre, any dentures should 
be removed and put safely away in a bowl of antiseptic lotion. The patient 
now being ready for the theatre, the hypodermic injection is admimstered, 
and after this he should lie quietly and be disturbed as little as possible. 

The nurse then collects the necessary bedcards and any X-ray photo- 
graphs or other evidence of the patient’s condition which may be required 
in the theatre. 

The preparation of a patient who is to have an operation per- 
formed under a local anaesthetic is very important. He will naturally 
be apprehensive, and fear that he will be hurt or may have to look at 
unpleasant sights and that he may lose his nerve. No suggestion on the part 
of doctors or nurses should contribute to these fears, and if he spealu of 
them he should be gently but confidently reassured. 

The patient should rest before the operation and have a good night’s 
sleep; lus bowels should be in regular working order, but he should not be 
given strong and unusual aperients. He need not be prepared by any pre- 
liminary starvation or purgation, and may have a meal which satisfies 
him a short time before the operation, but his stomach should not be 
overfull. 

For the hour or two immediately preceding the operation he should be 
kept as quiet as possible, undisturbed by noise or other sensory impres- 
sions. If necessary his bed should be placed in a quiet corner of the ward. 
About threequarters to one hour bcifore the time of operation he will be 
permitted to empty his bladder and have a drink of water; he will then 
be put on to the apparatus on which he will be moved to the operating 
theatre. This may be a stretcher, and in this case the theatre canvas will 



THE PREPARATION OP A PATIENT 633 

be put beneath him as he lies on the bed; or it may be a special trolley 
or bed on which he will be gently wheeled to the theatre. When comfort- 
ably arranged he will be given the sedative ordered such as morphia gr. 

I /6th to f, omnopon gr. J to or scopolamine i /120th to i/iooth. He 
must then be left entirely xmdisturbed, and should be advised to lie with 
his eyes closed. Some surgeons suggest that the patient’s eyes be covered 
and a little oiled cotton wool put into his cars in order to prevent sensory 
impressions from reaching his brain. The reason for soaUng the cotton 
wool with oil is that dry cotton wool is apt to move and make a gende 
crackling sensation which is irritating. When the time comes the patient 
should be quietly and gendy moved to the operating theatre, all talking 
must be avoided en route, and all unnecessary speaking avoided in the 
theatre. The movements of surgeons, doctors and nurses should be as 
noiseless as possible. 

Preparation of the skin (see illustration, fig. 213, p. 615). The pre- 
paration of the skin has undergone a good deal of change since the days 
of Lister. He prepared it by washing with i /20 carbolic and applying a 
lint compress of the same lotion. 

At the present time it is usual to shave the skin, and for this the razor 
should be sterile. Either an ordinary or a safety razor may be used. When 
possible it is advisable that the patient should have a bath after the skin 
has been shaved, as this will render his body quite free from stray hairs. 

The antiseptic preparation of the skin is next carried out. Many different 
preparations are used, including the aniline dyes, iodine and picric acid. 
A common routine in practice is: 

(1) To wash the skin thoroughly with warm water and liquid soap, then 
dry it with wool. Washing the area of the abdomen, for example, should 
occupy at least seven minutes. 

(2) Taking a dry wool swab saturated with methylated ether, the skin 
should be well swabbed in an endeavour to remove grease and get rid of as 
much epidermic debris as possible. 

(3) Swabbing with methylated spirit in order to dry the skin as 
thoroughly as possible should then be employed. 

(4) Finally, the prepared area should be painted with the antiseptic 
chosen and, when it has dried in, the area covered with a sterile towd or 
cloth which should be securely bandaged on. This dressing will be removed 
in the operating theatre. Some surgeons consider that the use of anti- 
septics on the skin lowers its vitality, and only permit the employment of 
alcohol for this purpose. 

In some cases certain modifications of the above method have to be 
considered to meet special needs. In the preparation of an acute ab- 
dominal catastrophe, for example, handling of the anterior abdominal 
wall is contraindicated, as it would cause pain and so increase the ten- 
dency to shock later on. In this case the entire preparation might be de- 
layed until the patient wais under a general anaesthetic; in less severe cases 
the skin might be shaved and painted with an antiseptic and covered with 
a sterile towel. A further case in which the use of antiseptics might be 
contraindicated, and the skin prepared witli saline compresses only, occurs 
when skin is to be taken for grafting purposes. 

Preparation of special cases. For operations on the mouth special care 
should be taken with regard to oral hygiene. Any necessary dental treat- 



634 


6PEIIAT10N TEGHNIQUE 



(A) Area of skin prepared for mastoidectomy, opening glands in axilla, Gallie’s rcpair 
of hernia, and excision of semilunar cartilage. (B) Area prepared for an operation on 
the kidney. (C) For radical mastectomy. 

ment should be undertaken first, and the teeth brushed and the mouth 
rinsed with an antiseptic thrice daily for a week or so before the operation. 

Before operations on the stomach or small intestine the mouth should 
receive the same careful attention. It may be necessary to have the patient 
on a light diet for some days beforehand, and, in some cases of gastritis, 
or where there is accumulation of fetid fluid in the stomach, lavage will be 
ordered lor two or three days beforehand. 

Before operating on the lower part of the alinientary tract, particularly in the 
rectal or anal region, efforts are made to render the colon as free from food 
residue as possible. Aperients are usually given 4 or 5 days beforehand and 
repeated as necessary until 48 hours before the operation. Enemata may 
be used daily to clear the lower part of the bowel but an enema should 
not be given later than 24 hours before the time of operation. An enema 
given, say 6-8 hours beforehand, irritates the colon and causes spasm with 
die result that fluid is retained, only to be returned to the great inconve- 
nience of the surgeon and the humiliation of the nurse as soon as manipu- 
lation of the parts is commenced. A non-residue diet may be given for 
from 5 to 7 days beforehand, the diet to include bland, non-irritating 
foods and cool fluids. In cases of intestinal obstmetion, in which persistent 
vomiting is a marked feature, the stomach will be washed out before an 
anaesthetic can be given. 

Before any operation by which the patient will be disabled during the 
days immediately following it, or an operation in which some specially 
rigid position will have to be maintained, it is most essential mat the 
patient should be fully conversant with the conditions under which he 
will have to live. A case of cataract (see p. 749), fbr example, should be 
taught to use the bedpan lying flat in be<4 and to take food fir^ a vessel 
in ^ same position. 



THE PREPARATION OF A PATIENT 635 

Moreover, when specially trying circumstances are to be anticipated, 
particular attention should be directed to the observation of the intelli- 
gence of the patient and the type of temperament he possesses, in order 
to note whether it is advisable to subject him to the necessary strain, or 
whether some less strenuous, even though it be a less useful, measure 
should be adopted. The responsibility is undoubtedly the surgeon’s, but 
the nurse can do much by her observation to help him in arriving at a 
wise decision. 

Before operations on the geniio-urinary tract it is particularly important to 
test the renal function in order to determine the degree of efficiency. For 
this purpose the blood urea and urea concentration tests will be performed* 
In many of these cases the blood pressure will be raised. This also requires 
investigation. 

In cases of low vitality and when anaemia is present it is important to csti^ 
mate the haemoglobin content of the blood, and if necessary improve it 
by blood transfusion before operation. This is almost invariably carried 
out before operation for partial removal of the stomach where the patient 
has probably been subject to starvation for some time. 

SURGICAL SHOCK 

Shock is the complication which is so dreaded and which so much of 
the preparation of patients for operation is directed at preventing. The 
state of shock is due to depression of the vital centres, the blood pressure 
is low, the capillaries are dilated and even though the patient may not 
have bled, owing to blood stagnation the sy mptoms are similar to those 
associated with severe bleeding. 

Syrr^toms characteristic of shock are a pale cold skin, feeble rapid pulse, 
subnormal temperature and shallow breathing, the face is pinched and 
pale, the eyes glazed and the mouth dry. The patient lies limp in his bed, 
he takes no interest in his surroundings, he may not be unconscious but 
he docs not move when spoken to. There is no restlessness. 

Treatment^ which is given in detail on p. 637, includes the provision of 
warmth and absolute rest, elevation of the foot of the bed to assist the 
blood back to the heart, the administration of fluids, including glucose 
with insulin when the blood sugar is low, and then, when the circulation 
is beginning to recover, the administration of stimulants. 



Chapter 41 

Post-Operative Treatment and Nursing Care, including 
the Management of a Surgical Dressing 

Posi*operaHv€ nursing: position^ prevention and treatment of shocks relief of 
disconforts following abdominal operations — Observations to be included in the 
nurse's report on t^ patient — Diet after abdominal operations — Action of the 
bowels — Care of the wound — Complications following abdominal operations — 
Management of a surgical dressing 

T he care of the patient after operation is a very extensive subject and 
will be considered under the following headings: 

(i) Position of the patient. 

(2) Prevention and treatment of shock. 

(3) Discomforts that the patient may suffer during the first 24 hours. 

(4) The report that one nurse going off duty will make to another, 6 or 8 
hours after the operation. The report a nurse should be prepared to make 
to the surgeon 24 hours later. 

(5) The diet and care of the bowels. 

(6) Care of the wound. 

(7) Complications. 

Post -operative nursing care. After any operation performed under 
a general anaesthetic, nursing care includes observation of the patient’s 
general condition and of his pulse, colour and respiration until he recovers 
from the anaesthetic; the arrangement of a suitable and as far as possible a 
comfortable position; the relief of minor discomforts which follow an 
operation, such as thirst and vomiting, and particularly with regard to 
whether the patient has passed urine; the administration of a fluid diet as 
soon as nausea and vomiting have ceased and the giving of a suitable 
aperient in order to obtain an action of the bowels as soon as convenient 
usually about the second or third day. The condition of the tongue, par- 
ticularly in abdominal cases, should be inspected daily; pain may need 
the administration of opiates; and complications should be watched for 
and recognized without delay. 

The manner in which a patient is received back from the operating 
theatre is described in the routine preparation of an operation bed on 
p. 78. Until he is round from the anaesthetic he will be carefully 
watched as mentioned above, very particular attention being paid to his 
colour and the degree of body heat, the strength of his pulse and the depth 
of his respiration. Any increasing pallor or cyanosis, weakness or imper- 
ccptibility of pulse, diminution in depth and rate of respiration, or loss of 
body heat accompanied by the collection of beads of sweat on the skin, 
should be looked upon as danger signals, indicating an immediate need 
for restorative measures. 

Position. The position in which a patient is placed as soon as he 
recovers from the effects of the anaesthetic depends upon the nature of his 
illness and the operation which has been performed. He may lie on his back 

636 



POST-OPERATIVE TREATMENT AND NURSING 637 

in a semirecumbmt position with a pillow under his knees after an abdominal 
operation. The foot of the bed may require to be elevated if shock is 
present. Fowler’s position is used in cases of peritonitis, and in all other cases 
in which drainage of the abdomen is desirable; it is also used in the post- 
operative nursing care of cases of gastric and duodenal ulcer, and aftor 
other operations on the stomach, partly to relieve the operation area of 
the weight and pressure of adjacent organs, and partly because this 
position so materially helps to a general sense of wellbeing. The patient 
who is propp>ed up and can see what is going on around him does not feel 
quite such an invalid as one who is obliged to keep quite still, lying flat 
in bed. Fowler’s position is also adopted in cases of most elderly and stout 
persons in whom the development of pulmonary complications might be 
feared. The prone position is not often used, though it may have to be em- 
ployed in some cases of laminectomy and is sometimes adopted for an hour 
or two at a time in the relief of flatulent distension of the abdomen. 

The prevention and treatment of shock. A junior probationer will 
undoubtedly be impressed by the amount she hears and learns regarding 
the prevention and treatment of shock, but she will soon be able to take an 
intelligent part in the teamwork carried on against this possibility, 
although despite all efforts the danger can never be altogether eliminated. 
Supposing an acute abdominal catastrophe arrives in hospital for imme- 
diate operation, the nurse will find that with all the bustle of arrival the 
surgeon may wait an hour or two before operating. This is because it 
would be unwise to operate on a patient who has sustained pain and fear, 
and perhaps suffered considerable jolting in an ambulance. The surgeon 
will wait until the patient gets a little wanner and more confident in his 
new surroundings; in the meantime the nurses must be busy getting him 
into a warm bed and applying external heat; and in some cases salines will 
be administered or a blo^ transfusion given during the waiting period. 

Care should be taken to prevent exposure of a patient after he has left 
his bed to wait perhaps in an anaesthetic room. He should be warmly 
clad and covered by warm blankets. He should not have to lie on a hard 
table but be placed on a sorbo mattress, folded blankets, or on a warm 
water bed. The nurse will do well to notice the high temperature of the 
operating theatre, and observe and imitate the care with which the 
anaesthetist inspects his patient before choosing the anaesthetic he will 
use, the gentleness with which the surgeon works and the care taken by all 
around the operating table to prevent exposure and unnecessary handling 
of the tissues under operation. 

The nurse who prepares the bed to which the patient is to return (see 
fig. ag, p. 153), will provide saline materials for rectal administration, 
and for the application of external heat and blocks at the foot of the bed 
in case of necessity; but the treatment for shock must often begin in the 
operating theatre in the form of administration of a blood tran^usion or, 
alternatively, of intravenous saline infusion or infusion of glucose, 10 per 
cent. When ^e patient returns to the ward either of these treatments may 
be continued, or a less serious degree of shock may be treated by the 
administration of rectal or subcutaneous salines given either continuously 
or at regular intervals. 

The nurse will wrap the patient in warm blankets, apply the electric 
cradle or hot water bottles as soon as possible and when he comes round, 



638 POST-OPERATIVE TREATMENT AND NURfilNO 

provided that nausea and vomiting are absent, will encourage him to take 
small drinks, unless contraindicated, as shock is most succ^fully treated 
by increasing the volume of blood fluid. 

The surgeon will order morphia which will relieve pain and discomfort 
and prevent painful impression fiom reaching the nervous system and so 
may result m the induction of sleep. Cardiac stimulants, including 
strychnine, caffeine and pituitrin, are less commonly employed as there 
is the danger that they may stimulate the circulation without improving 
the condition of the heart and so, by whipping up a tired organ, may result 
in producing a more serious degree of shock. 

Rest is another important nursing point. It applies to every circum- 
stance in which a patient may be in danger of shock or already suffering 
from it. Movement should be limited to a minimum; when necessary it 
should be performed gently and as smoothly and rhythmically as possible, 
avoiding all jolting or jarring. Very careful consideration should always 
be taken before a decision is made to move a patient suffering from shock, 
even to change a damp drawsheet, as in the case of a jjatient who is 
beginning to respond to treatment the movement involved might very 
likely be sufficient to cause a relapse. Some palliative measures can be 
taken; for example, the insertion of a small mackintosh and towel might 
be made without disturbing the patient in order to prevent his lying on a 
damp sheet. Routine nursing measures must never be permitted to control 
the nursing of a seriously ill patient — each case should be individually 
considered. 

DISCOMFORTS FOLLOWING AN ABDOMINAL OPERATION 

Certain discomforts may arise after an abdominal operation which will 
naturally be less marked after an imcomplicated appcndicectomy than 
after an operation for the relief of strangulated hernia, or in a case of 
appcndicectomy complicated by i>eritonitis before operation. 

Pain. A certain amount of pain will follow an abdominal operation 
because of the handling of the intestine and the incision made in the 
anterior abdominal wall. The nurse in charge should sec that pain and 
discomfort are not in any way contributed to by having the patient in an 
uncomfortable position. Every care should be taken to arrange pillows in 
order to provide adequate support, so that the patient’s ba^, abdomen 
and thigh muscles are not strained to maintain the position. The bandage 
should not be too tight; the top bedclothes should be light and rather 
loosely arranged, pressure across the abdomen, thighs and knees or over 
the fxt should be avoided. If a knee pillow is used it should be placed 
comfortably in order to support the thighs; if necessary a low bedcradle 
should be employed to take the weight of the bedclothes off the abdomen, 
and in this case the patient should be provided with a light blanket next 
to him, underneath the bedcradle so that he is snugly wrapped up. 

The patient should be carefully handled and the bed should never be 
jarred or shaken, as all such movements will cause the patient to contract 
involuntarily his abdominal musclm, and this movement would pull on 
the stitches holding the tissues together, and give rise to pain. As pain is 
likely to keep the patient awake, and this would delay his recovery fiom 
shock, the doctor will usually oifler an opiate on the first night. 



DISGOMTORTS FOLLOWING ABDOMINAL OPERATION 639 

Retention of urine. The abdominal wound will make the patient 
avoid all contraction of his abdominal muscles; the rigidly still position 
in Mdudi he rests in order to avoid this, combined with the fact that the 
nervous control of micturition may have been disorganized, pardy by the 
depressing effect of the anaesthetic on the central nervous system, and 
partly because of the handling of organs adjacent to the bladder during 
an abdominal operation, all tend to give rise to disordered micturition 
and retention of urine is the form this most commonly takes. This compli- 
cadon may therefore be eiqjected in many cases, and for this reason the 
nurse should always nodee when a padent passes urine and how much he 
passes. A specimen should be taken and examined for any abnormality; 
most anaesthedcs used are drugs which have to be eliminated from the 
body by means of the kidneys, and the renal cflSciency may be slightly 
unpaired during this process. Moreover, as before mendoned, an operation 
is an injury to the physical wellbeing of the padent and is consequently a 
strain on the functional activity of all organs. 

Treatment of Retention. The desire to micturate occurs normally whenever 
8-10 ounces of urine have accumulated in the bladder; the desire may be 
acutely felt and yet the patient may experience difficulty because the 
sphincter muscle is in spasm. It is at this time that the nursing measures, 
aescribed on p. 405, for the relief of retention should be applied. If the 
desire passes off it is probably because more urine has been secreted, and 
now considerable distension may occur before further discomfort is felt. 
It is important, therefore, to watch for distension of the lower part of the 
abdomen. A rapidly distending bladder should be relieved by cathe- 
terization. Most surgeons are agreed that overdistension is injurious to the 
bladder and prefer that it should be evacuated by catheterization. 

Abdominal distension. Some flatulence will occur after every 
abdominal operation, due to the handling of the gut, and if inflammation 
is present the distension will be more marked. A very serious de^ec of 
abdominal distension will occur in cases complicated by peritonitis. 

Treatment. The distension causes great discomfort, and results in tighten- 
ing of any bandage the patient may be wearing; this should be loosened 
sufficiently to relieve the discomfort. Altering the position of the patient 
may give some relief. A patient who is in the recumbent position might sit 
up. Some surgeons allow a patient with abdominal distension to lie in the 
prone position for an hour or two in order to get relief. If the patient is 
not vomiting, some carminative such as peppermint water may be given 
by mouth, and in cases where the gut has not been involved in the opera- 
tion an aperient may be given. 

The passage of a flatus tube will relieve if gas has accumulated in the lower 
part of the bowel; for an accumulation higher up a turpentine enema is 
valuable, or some other carminative enema, including asafoetida, 
molasses and alum (see p. 13 1). Applications of heat to the anterior abdom^ 
inal wall arc sometimes anployed but, unless the wound is covered by 
strapping and elastoplast, a hot moist application such as a fomentation 
would be inconvenient and might stimulate superficial bleeding. 

Abdominal distension which is unrelieved by these measures is probably 
due to temporary paralysis of the gut. This is described as paralytic ileus. 
It may occur in any part of the alimentary Ixact below the diaphragm, 
infill iHing the stomach. It gives rise to the symptoms of intestinal obstruo 



642 POST'OPERATIVE TREATMENT AND NDREINO 

(11) Whether the relatives have inquired about dte condition of the 
patient since the operation, and the reply which hats been given to diem. 
Indications should be given as to where the address or telephone number 
of the relative who is to be informed of any change is to be found. 

Report to surgeon. The following are the questions the nurse should 
be prepared to answer and the information she should be prepared to 
give to the surgeon who visits the patient for the first time 24 hours after 
the operation. 

The surgeon coming to the bedside will take in at a glance the general 
condition of his patient; the general attitude and position adopted in bed, 
the degree of interest the padent takes in his surroundings, the expression 
on his face, whether he is anxious and worried or calm and peaceful, the 
condition of the eyes, the dryness of the lips and tongue, and the state of 
the hands, whether they are tremulous or sweating, or lying quietly 
relaxed. This will tell him very much more than a chart at the beside, 
although on reference to it he will see the temperature, pulse rate and 
respiration rate, and the action of the bowels and kidneys. 

The nurse must be prepared to provide information regarding: 

The degree of shock following the operation and how this was treated, 
and the response to treatment. 

When the patient passed urine and the degree of abdominal distension and any 
treatment that has been used for this'including the passage of a flatus tube 
— ^with result, and whether a turpentine enema has been employed. 

Artf pain and discomfort the patient experienced, and the amount of sleep he 
has had. If he had a sedative the amount and time should be stated, and 
the amount of sleep induced by it. 

Whether the patient suffered very badly from thirst, and whether vomit 
was troublesome; the time when vomiting ceased and whether it was 
possible to give the patient fluids at the usual time, that is, about 4 to 6 
nours after the operation. If vomiting has been persistent since the opera- 
tion she should be prepared to specify the frequency with which it occurs, 
the character of the vomit, whether it is of the anaesthetic type, or whether 
it has become feculent. 

With regard to the dressing, whether there has been oozing, and how 
this was dealt with; if tubes were inserted the dressing may have been 
changed and the nurse should be able to describe the amount of discharge 
present. 

DIET 

The diet after the administration of a general anaesthetic for whatever 
purpose it may have been given will depend upon the degree of nausea 
and vomiting present. In the nursing care of cases of general abdominal 
surgery, certain routine methods are adopted by most surgeons, but these 
should not be slavishly adhered to, and as far as possible the patient’s likes 
and dislikes should be considered as well as his general condition. 

In most cases the nurse should be sparing with fluid by mouth for 6-8 
hours, allaying thirst by rectal salines, and by cleansing and moistening 
the mouth. Provided that nausea and vomiting have ceased she may then 
give small drinks, say 2-3 ounces every 1-2 hours. 

Table of diet after uncomplicated appendlcectomy. 

For the first 6 hours as little as possible by mouth. ^Ur 6 hours, if nausea 



DIET 643 

and vomiting have ceased, watery fluids, including weak tea, may be 
given in small quantities, for example 3 ounces every hovir, or 4 ounces 
every a hours. 

First dt^ — fluids such as barley water, lemonade, soda water, weak tea, 
milk and water 5-7 ounces every 2 hours, with as much water as the 
patient Avill drink in addition. 

Secom day — very light diet such as bovril, or light soups, jelly, thin 
bread and butter, custard. 

Third day — by this time the bowek have acted, and the patient will feel 
capable of taking a fuller diet; he may therefore have a little lightly 
steamed fish and potato, milk pudding, lightly boiled egg and fruit. 

Subsequently, the diet may be increased, but large quantities of green 
salads or green vegetables and red meat should as a rule not be allowed 
whilst the patient is lying flat in bed. 

Table of diet after an operation on the stomach, for example, 
partial gastrectomy. 

First twelve hours — nothing by mouth, but rectal salines are adminis- 
tered. 

After 12 hours, the patient may have small drinks of water every hour. 
This is preferably given warm and in small mouthfuls, say | ounce at a 
time, or larger drinks say 1^2 ormccs every 2 hours. Frequent mouth- 
washes should be given. 

On the second day — by noon the second day the patient may be having 
as much as 4 ounces at a time, including milk and water diluted half and 
half every 2 hours, and if he wishes he may have drinks of plain water in 
between. 

By the fourth day, the patient is having drinks of milk, which may be 
flavoured, 5-6 ounces every 2 hours, and water in addition. 

On the eighth day he is given a little light diet, including bovril, tliin bread 
and butter, jelly, or custard. 

Subsequently, the diet is increased by the addition of lightly cooked eggs, 
toast and butter, milk pudding; after 2-3 weeks pounded fish and chicken 
cream are added, and later minced chicken and potato are allowed. 

OPENING OF THE BOWELS 

If the alimentary tract is well prepared before operation, there is no 
need to consider the necessity of making the bowels act during the first 
24-48 horns. If, however, the operation was an emergency one, the sur- 
geon may consider ordering a small enema in order to empty a bowel 
which is overloaded. In uncomplicated cases of abdominal surgery an aperient is 
usually ordered on the second evening following operation. An aperient the patient 
has been in the habit of taking should, if possible, be used. It is important 
that one be employed which will not disturb the patient during the night — 
a small dose of cascara or infusion of senna pods is a suitable example. If a 
more rapidly acting aperient is used, or if the patient is likely to be dis- 
turbed by the knowledge that he has had an aperient, it should be given 
on the morning of the second or third day so that it will act in the day 
time. In either case the muse should tell her patient not to worry about 
the action of his bowels or the effect of the aperient. If it does not act she 
should tell him it can be repeated, or a small enema may be given so that 



644 POST-OPERATIVE TREATMENT AND NURSING 

anxiety and straining at stool will be avoided. A number of surgeons order 
liquid paraffin three times a day from the second day until the bowels 
have acted, particularly after operations on the stomach or following 
resection of the gut, as in these cases considerably longer rest will be re- 
quired. If the bowels have not acted by the fourth day a smsdl enema is 
usually given. An enema is invariably ordered if there has bet^p much 
distension. 


GARB OF THE WOUND 

A clean stitched incision usually heals by first intention (sec p. 580). 
The wound is protected by a dressing of gauze and wool, but opinions 
differ as to the best means of retaining this in position, and incline to the 
use of clastoplast or Whitehead’s varnish, omitting the use of a bandage or 
binder which so soon becomes tight and uncomfortable. The stitches will 
be removed between the 7th and loth days — for method of removal, sec 
p. 625. The dressing will not be disturbed until then unless it becomes 
uncoirfortable. 

Drainage of wounds. When a drain is employed, it is usually because 
infection is present, and it may be carried out by means of a gauze wick, 
rubber tube, or corrugated rubber tubing and, when the peritoneal cavity 
has to be drained, by the use either of long firm rubber tubes or perforated 
glass ones. The tubes should not extend very far beyond the level of the 
skin because, if pressed on by the dressing and bandage, discomfort will be 
caused. 

The amount of discharge will determine the date of the first dressing, 
which may be done after the first 12-24 hours, the gauze and wool being 
changed, the tube inspected to see that it is acting effectively, and the 
surroimding area cleansed with antiseptic lotion. (For further details on 
the management of a surgical dressing see p. 649.) 


COMPLICATIONS 

In addition to shock and the discomforts described on p. 638, other 
complications which may follow an abdominal operation include: 

Complications of a wound. Sepsis may occur in the following 
forms: A stitch abscess is infection of the puncture wound made by the 
needle in which tlie stitch lies; the treatment is to remove the stitch and 
either paint the inflammatory area with an antiseptic such as iodine, or 
apply a hot moist dressing, in the form of a fomentation. Subcutaneous 
suppuration may occur, especially in wounds in which large skin flaps have 
been made. This is usually due to a collection of serum and pus beneath 
these, which prevents healing. The treatment is to evacuate the fluid, and, 
if suppuration has occurred, to apply hot fomentations. Haematoma may 
occur, and when it docs it is usually in the deeper tissues, where a collec- 
tion of blood has been retained. 

Rupture of stitches and escape of intestines. This complication may 
occur early owing to strain of the abdominal wall by coughing and vomiting, 
or by continuous restlessness in which vigorous movements are constantly 
made by the patient — wild throwing about of the legs, for example, is likdy 
to strain the abdominal wall. In some cases the gut may escape through a 
small opening in the wound at the side of a large drainage tube. Gut is 



COMPLICATIONS 645 

very slippery and elusive, and behaves rather like quicksilver once it 
escapes from the abdominal cavity. 

When the wound gapes and die gut escapes a week or so after the operation, 
it may either be due to sepsis, or to the fact that repair of the tissues has not 
occturred by the time the deep catgut sutures have been absorbed. This 
sometimes happens in patients in whom the vitality is very low. 

Treatment. Unless the nurse has experienced the care of a patient in 
whom this complication has occurred, it is difficult for her to visualize the 
degree of mental anxiety rapidly followed by prostration which the patient 
suffers. The fost duty, therefore, is to reassure the patient, send for the 
doctor and, in the meantime, collect any intestines which may be lying 
around the patient in the bed, in sterile towels wrung out of warm s^ne 
solution. In no circumstances should the nurse attempt to undo the ban- 
dage or binder as by so doing she will permit the wound to open still more, 
and all the intestines will rush out. Instead, having collected all the es- 
caped intestine in warm towels she should bring the drawsheet up against 
the patient’s sides, in order to exert pressure on the sides of the abdominal 
wall and so make some attempt to help keep the wound in apposition. 
The surgeon will probably order morphia, and the nurse should prepare 
to take the patient immediately to the operating theatre. She should 
not attempt to get a specimen of urine, as the act of micturition is 
normally assisted by contraction of the abdominal muscles and this may 
give rise to a further escape of intestine, but she should prepare a catheter 
to take to the theatre. 

Haemorrhage. Haemorrhage may occur. When this happens during 
the first twenty-four hoiu^, it is probably due to the slipping of a ligature 
and will be treated by taking the patient back to the operating theatre 
and having the bleeding vessel tied. Bleeding may be visible — when it is 
easily recognized — or internal, and therefore a surgical nurse should be 
very familiar with the symptoms of internal bleeding (see p. 571) and so be 
able to recognize them before the patient is in serious danger. 

Secondary haemorrhage may occur from about 7-10 days Jifter the opera- 
tion and is almost invarialjly due to sepsis. It also requires investigation 
and treatment of the bleeding vessels. 

Cardiac and respiratory failure is usually preceded by shock, and is 
likely to occur mostly in seriously debilitated persons or those who have 
lost a lot of blood, or in whom for some other reason the haemoglobin 
content of the blood is low. 

Paralytic ileus, as occurring in cases of intestinal obstruction, and 
after resection of the gut, has been previously mentioned on p. 639. 

Pulmonary complications occur most usually after operations on 
the mouth, throat and chest, and also in elderly fat patients. Bronchitis is 
amongst the commonest. Hypostatic pneumonia is met in elderly persons. 
Massive collapse of the lung occurs after operations on the upper part of the 
abdominal cavity when the movements of the diaphragm are likely to be 
embarrassed. The first symptoms of this condition arise about the third 
day and include dyspnoea, a rise of temperature and pulse, and threatened 
cardiac failure. 

* 

Pulmonary embolism, which is a comparatively rare complication, 
is due to a clot from one of the small vessels in the vicinity of the operati<m 



646 POST-OPERATIVE TREATMENT AND NURSING 

area, which reaches the heart in the venous return, and is thence conveyed 
by the pulmonaiy artery to one of the lungs, where it passes along in the 
circulation until it reaches a vessel too small to carry it. It lodges there and 
the area of lung to which this vessel is passing is put out of action. This 
complication may occur at any time, cither during the early days, a week 
or so later, or during convalescence. The symptoms of a slight embolism arc 
dyspnoea and cyanosis; a more serious attack will seriously embarrass the 
heart and respiration. The symptoms may be very severe and sudden 
death occur. 

Treatment Dyspnoea causes the patient to sit up in order to obtain 
relief; he should be supported in this position by a nurse until pillows can 
be arranged to keep him erect. Oxygen should be administered in order 
to help the remaining lung to compensate for the inefficiency of the 
disable part, and also to assist the work of the heart in maintaining the 
circulation. Morphia is given because it is essential for the patient to be 
kept at rest, and he must be quite still and free from restlessness and 
anxiety. It will also relieve the pain in the chest; in addition, hot applica- 
tions are sometimes employed but, if they necessitate moving the patient, 
the nurse must remember that movement is definitely contraindicated. 

Subsequent nursing and treatment will aim at keeping the patient quiet, 
and the blood pressure low. A light, non-stimulating diet and cool fluids 
may be given. Mild aperients should be used in order to keep the bowels 
acting freely or small enemata may be employed. All mental excitement 
must be avoided, and the nurse should therefore be very judicious in her 
choice of the visitors she permits the patient to have. 

Lobar pneumonia is a rare complication, but inhalation and aspiration 
pneumonia may occur when blood and mucus have been indrawn during 
breathing, as may happen after operations on the mouth and thioat. 
This variety of pneumonia is frequently of the type described as ‘septic 
pneumonia', which is rather similar to broncho-pneumonia in which the 
patient runs an intermittent temperature, and has a veiy^ rapid pulse. The 
disease is prolonged over 2 or 3 weeks, results in marked prostration, and 
the temperature eventually declines by lysis. (See also p. 34.) 

Prevention of pulmonary complications. A nurse can do much to 
prevent the occurrence of pulmonary complications, and particularly 
those of an inflammatory nature, such as bronchitis and pneumonia. It is 
very easy for the patient to be chilled, particularly when he is unconscious 
and anaesthetized as at this time his blood pressure is low. The special 
theatre clothing provided in many hospitals includes a warm bed jacket 
and long woollen leggings, and aims at the prevention of chilling. The 
patient should be warmly wrapped up as he is taken along corridors in 
transfer from ward to theatre and back again, and the nurse attending the 
anaesthetist should see that the patient^s chest and the upper part of his 
trunk are covered before the sterile sheets and towels are placed across 
the table. As soon as the operation is over the nurses should remove any 
damp or wet clothing, replacing it by dry clothing, covering the patient 
and wrapping him up warmly before he is moved from the theatre. 

During the days following the operation nurses must remember that the 
patient’s vitality and consequent resistance to disease have been tem- 
porarily lowered; the strictest care should be taken to see tihat he is never 
exposed to chilling, particularly when his bed is made, when he is given 



COMPLICATIONS 647 

the bedpan, and when the wound b inspected or the dressing changed. 
Every little treatment that b performed during these days and every 
movement of him should, if p)ossible, be followed by the adminbtration of 
a warm drink, with careful inspection of hb extremities for coldness and 
applications of heat when necessary. 

It b important to realbe that the danger of pulmonary complications 
b increased by the presence of mucus in the respiratory tract during 
anaesthesia, and that the injection of atropine given beforehand b to 
combat thb danger; but the danger does not end here, and nurses must 
not look on atropine as a mascot against pneumonia — the hygiene of the 
mouth, for example, requires very careful attention in order to prevent 
the inhalation of septic matter. 

Uraemia may occur after any abdominal operation but more particu- 
larly so after operations on the genito-urinary tract, or when the patient 
has some renal dbability. The symptoms are those of diminbhed urinary 
output, and the urine contains albumin. The skin b dry, the bowels con- 
stipated, the mouth dry and the tongue furred, the patient complains of 
headache and becomes drowsy and, if the condition is allowed to proceed, 
the patient will pass into a state of uraemic coma. 

Thrombosis. Venous thrombosis of one of the veins of the lower limb 
may occur after operations on the abdomen and pelvis. Thrombosis may 
occur in a vein in the arm after radical mastectomy; sepsb b a predisposing 
cause of the condition, and so also b stagnation of the blood in the veins of 
the limbs which the patient tends to keep very still after an operation in 
their vicinity. In the case of the lower limbs this rigidity b often increased 
by the injudicious use of a knee pillow which renders the thighs immov- 
able. When a knee pillow b employed, the knees should be extended 
whenever it b removed for nursing purposes. 

The symptoms of thrombosb are pain, heat and swelling over the affected 
vein, accompanied by a rise in temperature and the other symptoms 
associated vrith the febrile state. The treatment is absolute rest to the limb, 
forbidding any movement, either active or passive. The limb should be 
elevated on a pillow and protected by a cradle bearing the weight of the 
bedclothes. The affected area is usually painted with glycerine of bella- 
donna, the dressing being maintained in position by means of a many- 
tailed bandage made to fit the limb, which prevents any movement of the 
limb when the dressing b changed. 

A portion of the clot may become dislodged by movement and so, 
travelling in the blood stream, give rise to pulmonary embolbm (see abo 
pp. 376 and 645). Therefore, in order to prevent the possibility of this 
complication, the patient must be nursed in a manner which would pre- 
vent any rise in blood pressure, so the diet should be light — it may be 
nourbhing, but should not be stimulating — the boweb should be kept 
freely acting in order to avoid any straining at stool and the patient should 
not be permitted any excitement either of pleasure or anxiety. 

Delirium tremens will only occur in patients who are in the habit of 
taking alcohol regularly, and who may be looked upon as chronic alco- 
holics. When an accident happens, or an operation b performed, and the 
system receives a shock and, at the same time, the patient b deprived of 
alcohol, a very serious type of delirium sometimes sets in. It b for thu 
reason that a very careful hbtory is taken, particularly of men patients 



648 POST-OPERATIVE TREATMENT AND NUR8INO 

when they are suddenly admitted to hospital, and that, if they are in the 
habit of taking alcohol, it is usually ordered in small re^ar quantities in 
order to try to prevent delirium tremens. 

The seriousness of this complication cannot be overestimated as the 
prostration resulting from it is in many cases fatal. 

A patient with delirium tremens begins by being unable to sleep, he 
then gets ill tempered and suspicious, and has hallucinations. The treatment 
as already mentioned includes the administration of alcohol; keeping the 
bowels acting freely by giving saline aperients; and the administration of 
sedatives, including bromide and chloral, hyoscine in doses of about 
1 1 100th of a grain, and morphia in doses of from i to J gr. 

Post-operative mania. This complication is fortimately compara- 
tively rare, but it is very serious when it does occur, as it usually necessitates 
removal of the patient to a mental hospital and the surgical treatment may 
have to be interrupted. 

Sepsis. Sepsis of the wound has already been dealt with; sepsis pre- 
disposes to the complications of venous thrombosis and pulmonary 
embolism. In addition, sepsis in the abdominal cavity is a complication to be 
feared in all cases of abdominal surgery. The condition is accompanied by 
a rise of temperature and the symptoms which accompany the febrile state. 
In abdominal surgery the condition of the mouth and tongue are fre- 
quently inspected by surgeons and nurses; thirst, dryness of the mouth and 
a dirty tongue are very often the first signs of this complication. 

A pelvic abscess, or a faecal fistula, may complicate appendicec- 
tomy, particularly if the appendix is perforated or gangrenous. Portal 
pyaemia is infection of the liver whidi has reached it from an infected 
abdominal cavity in the portal circulation. This condition is very grave, 
the patient runs an intermittent temperature, intercepted with rigors, he 
has a very rapid pulse, sweating is profuse and there is grave collapse. 

Subphrenic abscess may occur. It is to prevent the tracking of pus 
along the jKWterior abdomin^ wall to the diaphragm, that Fowler’s posi- 
tion is adopted. Keeping the patient sitting as erect as possible when in 
this position is an important nursing point. Although a subphrenic 
abscess may follow appendicectomy, it is a complication most to be feared 
after operations on the organs of the upper part of the abdominal cavity, 
including the stomach and gallbladder. Empyema may also complicate an 
abdominal operation. 

Peritonitis is a very serious complication. It is most likely that infec- 
tion was already present at the time of operation and, in spite of the care 
employed in the drainage of the abdomen, general peritonitis sets in. The 
onset is usually gradual, the symptoms not being very marked until the third 
or fifth day; the temperature then rises, the pulse rate quickens, the 
respiration fate increases, there is thirst, the mouth is dry and the tongue 
dry and dirty. Vomiting very soon follows, becoming feculent in character 
and being brought up without effort. The abdomen becomes increasingly 
distended, painful and rigid. The patient lies with knees flexed in order to 
relax the abdominal waU. The arms arc thrown above the head in an 
endeavour to help the respiratory movements which are thoracic in 
character, because movement of the diaphragm is restricted by the 



GOICPLICATIONS 649 

rigidly painiul abdomen. Hiccup accompanies the condition, which is 
imially very troublesome and adds considerably to the patient’s discom- 
fort. 

The treatment is surgical investigation of the state of the abdomen and 
free drainage of the cavity, the administration of rest and of fluids in order 
to help eliminate toxins from the body. 

Nursing care. In dealing with a case of peritonitis the nurse is dealing with 
a very seriously ill patient, who is suffering from toxaemia and markedly 
prostrated; in addition he is inconvenienced by persistent vomiting, hic- 
cup, and a painful, distended abdomen. 

The administration of fluids becomes a difficulty as the stomach rejects 
anything that is put into it, and fluids must therefore be administered by 
various other channels. In some instances the surgeon will wash out the 
stomach in an endeavour to rest it, and enable fluids to be taken by mouth; 
in other cases he will provide some continuous drainage apparatus in order 
to keep the stomach empty. The patient may have constipation or he may 
suffer from diarrhoea — in the former instance the nurse should be pre- 
pared to empty the bowel by small enemata daily. 

The persistent vomiting and the high temperature rapidly result in 
marked emaciation, thus enhancing the tendency to bedsores, which must 
be carefully prevented. The skin requires care as perspiration is profuse. 
Rigors have to be treated as they occur, the nurse keeping a careful record 
of temperature, pulse and respiration, and being constantly at the bedside 
of the patient who, by nature of his condition, is very restless and irritable, 
his senses are acutely active, and he frequently requires nursing attention 
in an attempt to obtain relief from the many discomforts he is suffering. 

THE MANAGEMENT OF A SURGICAL DRESSING 

In a surgical ward a dressing trolley is always in readiness and, as soon 
as it has been used, soiled articles are washed, sterilized and replaced, so 
that the wagon or trolley is always ready for action (see fig. 215, p. 616). 
It usually contains the following articles: 

Sterile towels, dressings and antiseptic swabs. 

Mackintoshes for protection of the bed. 

Sterile bowls for lotions and swabs. 

A sterile receiver in case a sterile specimen is required and non-sterile 
receivers for instruments, &c. 

Instruments, ready sterilized and placed in spirit or some antiseptic 
solution, such as lysol. These instruments should include Gheatle’s lifting 
forceps, Spencer-Wclls’s artery forceps, dissecting, dressing and sinus 
forceps, probes, directors and scissors. 

Sterile rubb^ tubing or some other provision for draining. 

Bandages of different types, some non-sterile ones, with safety pins 
attached, and others sterile in the dreeing drum, with safety pins ready 
sterilized in* the instrument dish. 

Antiseptic lotions, and materials for cleansing the skin, including 
methylated spirit, methylated ether, ether soap and iodine. One or two 
glass measures. 

Boracic powder. 

A lubricant, such as sterilized vaseline or glycerine. 

Sterile test tubes. 

PF 



650 POST-OPERATIVE TREATMENT AND NURSING 

A receptade for soiled dressings and another for used lotions. 

The surgeon may wish to do some of the dressingB himself, or on other 
occasions ^e ward sister may wish him to see some of them, but as a rule 
dressings are done by the sister or house surgeon who are attended and 
assisted by one or two nurses in training. Nurses are permitted to do simple 
dressings at first, and senior nurses, as they become prescient, will be 
allowed to do more difficult ones under supervision. 

A patient usually and quite naturally dreads the first dressing, but the 
nurse as she makes the necessary preparation for it can do very much to 
relieve his mind and allay his fears. She should move qtiiedy and without 
fuss, and thus by her maimer inspire him with confidence — an occasional 
nod and smile and cheery word will probably succeed in setting him 
almost at ease. 

In completing the preparations she will bring to the bedside everything 
likely to be needed, carefully explaining, if necessary, that they will not 
all be used on him. She will screen the bed so that the patient is not 
exposed to the gaze of others in the ward. 

The bedclothes will then be arranged — if, for example, an abdominal 
wound is to be dressed, the top bedclothes will be turned down to the level 
of the upper part of the patient’s thighs, leaving the pubes covered vrith 
a sheet and one blanket which can be turned over out of the way at the 
last minute. The patient should have some extra clothing on the upper 
part of his body which should be so arranged that it can be pushed up out 
of the way; the nightdress should be rolled up under the patient’s arms or 
the pyjama jacket folded back. 

The patient should be lying in the scmirecumbent position with his 
arms by his sides. He should be comfortable and the nurse should question 
him as to whether a little support either ‘here’, or ‘there’, is not an im- 
provement. The bandages should then be loosened or removed. When the 
surgeon or sister who is to do the dressing is ready to begin, the nurse will 
fold the lower clothes down and the upper ones back, and remove the 
already loosened bandage. She should lift off the top covering of wool with 
forceps, place it in a receiver, then hand the towels which the operator will 
arrange roimd the area to be dressed — ^partly in order to protect the bed- 
clothes from being soiled and partly in order to ensure an aseptic surround- 
ing of the part, and a place on which instruments or dressings can be 
placed if desired. 

The nurse having collected everything necessary at the bedside, with 
knowledge of the details of the steps of the procedure, hands each article 
as needed. After the dressing the nurse will help to replace the bandage. 
She should then give the patient a drink if he is allowed one, and as she 
remakes the bed should note whether his feet are warm, and whether his 
hot water bottle needs refilling. The articles used should all be quickly re- 
moved, and the things that the patient may have been using, such as 
reading materials, be placed within his reach. 

Surgical Dressing Rooms. It would be ideal if all surgical dressings 
could be performed in a special room, adjacent to die ward, set apart ibr 
this purpose. This is not always possible and the following instructitms 
entitled ^Routine jor Surgical Dressings’ as carried out in Sheffield are repre- 
duced here by the courtesy of Professor Price and the Matron of the 
Sheffield Royal Infirmary. 



ROUTINE rOR SUROICAU DRESSINGS 


651 


ROUTINE FOR SURGICAL DRESSINGS 

Irifection in wards is carried by: 

(i^ ‘Droplets’ fiom the nose and mouth. 

^21 Hands, instruments, and utensils. 

(3) Dust. 

Therefore 

(1) All the ‘Dressing Team’ must wear a mask. 

This must be put on after the hands have been rendered socially 
clean by washing. Do not touch the face or mask again after it has 
been put on, and, when removed, the mask must be put at once into 
the receptacle provided and not used again until it has been washed 
and re-sterilized. 

(2) All dressings must be done with sterile forceps. 

(3) The routine dressing round must not be commenced until at least 
one hour after the b^ have been ‘made’ and the floors swept. Ward 
doors and windows are closed to prevent draughts during ‘dressings’. 

Order of Dressings: 

(1) Clean all wounds without drainage. 

(2) Glean wounds with drainage. 

(3) Infected wounds. 

FIRST-TIME DRESSINGS SHOULD BE DONE FIRST UNLESS 
KNO WN TO BE ALREADT INFECTED 
Technique. Sterile towels must be placed so that the dressing area is shut off 
from bed linen and blankets. 

The Dressers wash their hands until socially clean and then rinse them 
in the solution provided. 

The Dressing is done with forceps. 

After the dressing, the used instruments and utensils are washed and 
boiled for two minutes before being used again. 

The dressers again wash their hands under running water as hot as 
can be comfortably borne. They are dried on a sterile towel after being 
rinsed in the solution provided and then proceed to the next dressing. 

STERILE GLOVES MUST BE WORN FOR ALL SEPTIC CASES 
The Assistant places the patient in position, so that the breath and 
droplets from the p>atient cannot contaminate the woimd. The superfi- 
cial dressings are removed and later reapplied by the assistant after the 
dressers have finished. 

The Trolley Attendant hands out the toweb, instruments and dressings 
with Ghcatlc’s forceps, and using another pair of forceps removes the 
dirty dressings into the receptacle provided. These dirty dressings are 
removed from the ward immediately the dressing of each case b fimshed. 

NOTE. Plasters should not be removed in the ward. 

Gloves and gotvns should be worn when dirty linen b sorted. 

Syringes and needles used for injection must be kept separately from 
those used for aspiration. 

Skrile instruments should be kept in the solution provided. 
MAKESHIFTS MAKE MORTAUTT 



65s POST-OPERATIVE TREATMENT AND NURSINO 

Painful Dressings. In some instances an anaesthetic xnay be necessary 
for the performance of a dressing, as for example in diildrra, in the first 
dressing after operation for mastoiditis and in the first dressing of an 
amputation. In other cases, pain may be lessened by the administration 
of a hypodermic injection of morphia, as for example in the first dressing 
for the removal of a vaginal packing after Wertheim’s hysterectomy has 
been performed, and in cases where a large area of bone has been gutted, 
as in the surgic^ treatment of osteomyelitis. 

Large dressings with flaps and drainage tubes. Some cases such 
as amputation of the thigh or radical mastectomy will have large skin 
flaps which have been sepEu-ated from the tissues beneath and turned back 
during the operation. These flaps have been deprived of blood for some 
time and, when brought back over the surface which has been operated 
on, and placed in apposition, they may not adhere to the underlying 
tissues. It is important in dressing such cases to observe whether the flaps 
appear to be adhering or whether they are ballooning from the underlying 
surface — ^which would indicate a collection of serum. In most cases the 
surgeon will have inserted a drainage tube of some description, either a 
circular rubber tube, or corrugated glove tubing. The nurse should note 
whether the tube is acting as an effective drain, or whether the area into 
which it has been inserted has been blocked by clot. In this case she might 
move the tube gently, or if it is not stitched in she might take it Dut, 
iterilize and reinsert it, or it might have slipped out. In all cases where the 
nurse is dealing with large flaps, she should gently palpate the surface in 
order to detect the pocketing of serum and, by smooth even stroking 
movements, direct this fluid in the direction of drainage. 

Another point is that in some instances a considerable area of super- 
ficial tissue may have had to be removed, and the amount left to form 
flaps may require considerable tension in order to bring the edges into 
apposition. In this case the nurse must watch carefully to see whether the 
tension stitches are exerting too great strain or pressure on the skin. If the 
edges are separating she might devise some means of easing the tension on 
the sutures. In some cases, the flapis are bound to separate and a skin- 
grafting operation will probably be performed later. 

In other instances the flaps may have been considerably bruised. This 
renders them moist and sloughing may occur. It is a very important 
nxusing point in these cases to keep the tissues as dry as possible with 
some powder, such as aristol. The dry tissues being a less suitable medium 
for the growth of organisms, healing is more likely to take place. 

With regard to rubber drainage tubes, it is always necessary to see that they 
do not become adherent to the tissues in which they are placed. In the 
case of amputation of breast, the tubing is for supeificial drainage pur- 
poses and will usiially be taken out in 48 hours. In the case of nephrec- 
tomy, the tubing is deeply placed in the tissues and can be uightly 
shortened, about j or J of an inch every day, until it can come out. 
After cholecystectomy has been performed, corrugated tubing may be 
placed between the muscles at the side, below the operation incision. In 
this way bile is prevented from collecting routul the actual wound, and 
any bile will drain away between the muscles with less likelihood of the 
formation of a biliary fistula. When cholecystotomy has been poformed 
it will be necessary to provide for the tirainage of bUe firom the wound for 



ROUTINE FOR SURGICAL DRESSINGS 653 

some days. In this case Paul's tubing may be used and the bile conducted 
into a bottle at the bedside. 

In cases of laparotomy for the relief of peritonitis, or the removal of a 
perforated appendix, several tubes will be inserted, both in front and at the 
side of the abdomen. Those at the side will usually be taken out and re- 
placed each day, the one in the middle line probably being stitched in. 
In dressing the wound a syringe with rubber tubing attached should be 
placed through the tube in order to draw off fluid by suction. On the 
third or fourth day the stitch holding the tube will usually be cut and the 
tube moved and, once pus has ceased to drain and only serum is now being 
obtained, the tubing v^l be removed and a smaller one inserted. 

Spirit dressings. An application of spirit covered by jaconet and wool 
is employed in the treatment of local septic conditions. It is used both in 
mild forms as when a septic finger may be imminent and by the antiseptic 
action of the alcohol or spirit this may be prevented from developing. It is 
also used in the treatment of serious and advanced septic conditions, 
as when employed as an application to a carbuncle for example. 

The precaution of warning the patient of the danger of fire should be 
taken. A man with a spirit dressing on his face should not light a cigarette, 
as it may set fire to the dressing. A person with a spirit dressing on the 
finger should not, for example, approach near to a fire, or use matches. 

Collodion dressing. Collodion is often used for the purpose of sealing 
small puncture wounds such as are made when performing lumbar 
puncture or exploration of the thorax. 

Flexile collodion^ which is compK>sed of pyroxylin, castor oil, ether and 
alcohol, a very inflammable mixture, is the variety employed. As this 
will not adhere to a moist surface it is essential to dry it first, then the 
collodion may be painted on with a brush, or poured on to a circular 
piece of gauze or hnt which is placed on the wound; sufficient collodion 
should be used to seal the edges of the cotton dressing and bind it to the 
skin all round. Collodion can also be employed to arrest bleeding from 
small cuts; in this case the skin on each side of the cut should be pinched 
up between the thumb and finger, wiped free of blood to dry it, and with 
the edges in apposition a collodion dressing is applied. When firmly 
set the tissues arc released, and the firm collodion dressing maintains the 
parts in apposition and so arrests the bleeding. 

Whitehead^s varnish. This is another gluelike preparation which con- 
tains, in addition, iodoform. It is a very useful dressing for wounds on the 
face and whenever a wound requires protection fium wetting or friction. 
To apply, a layer of cotton wool is placed over the wound and the varnish 
painted over this, taking care to se^ the margins of the cotton wool down 
on to the surrounding skin where they will adhere. 



Chapter 42 

Common General Surgical Conditions Treated by 
Operation, including Some Points in the Pre- 
paration and Post-Operative Care 

Acute abdominal conditions: injlammation^ obstruction and perforation — Appen- 
dicitis: symptoms^ post-operative nursing — Operations on the stomach — Hernia — 
Haemorrhoids — Resection of colon^ colostomy and perineal excision of rectum with 
notes on post-operative nursing — Thyroidectomy: preparation and post-operative 
nursing care — Operations on the breast and post-operative nursing care — Operations 
on the thorax — Amputation of a limb 

ACUTE ABDOMINAL CONDITIONS 

A n acute surgical abdominal catastrophe will usually be due to one 
of the three following causes: 

L Some acute infiammatory condition 
Acute intestinal obstruction 
Perforation of hollow viscera. 

The first thing the probationer nurse will probably notice is the simi- 
larity of symptoms complained of in each of these cases. Pain is invariably 
present, varying in intensity from a tiresome ache to an acute agonizing 
degree of pain which renders the patient rigid and afraid to move. 
Vomiting is also varied, and most patients will complain of nausea; some 
will vomit once or twice, the material consisting of stomach contents, 
while others will suffer from persistent vomiting of a more serious charac- 
ter. Some degree of collapse will usually be present, varying from a mild 
degree of coldness to the acute condition describe under shock on p. 
635, in which the extremities are cyanosed, the skin is cold and clammy, 
the pulse feeble and the breathing shaUow. The temperature, pulse and 
respirations may or may not vary; the temperature may be high in an acute 
inflammatory condition or markedly low in collapse; the pulse will vary 
with the amount of shock when pain is present, and the respirations with 
the extent to which movement of the anterior abdominal wall is interfered 
with as a result of pain or of abdominal distension. 

(a) Inflammation. The commonest cases of inflammation admitted 
include those of appendicitis, acute cholecystitis, salpingitis and diverti- 
culitis. The inflammation is at first local, but it usually spreads to the 
peritoneum and then gives rise to the characteristic symptoms of peritoni- 
tis. 

(b) Intestinal obstruction. Any mechanical disturbance will give rise 
to some degree of obstruction, the causes including strangulated hernia, 
in which the obstruction may be partial or complete, volvulus, adhesions, 
tumours, intussusception, and impaction of the small intestine by gall- 
stones. 

The symptoms of intestinal obstruction arc characterized by pain, which is 
intermittent and colicky in character and varies in intensity — this pain is 

654 



ACUTE ABDOMINAL CONDITIONS 655 

due to the increased rate of peristalsis which occurs as the involuntary 
muscle contracts in order to try and overcome the obstruction and pass 
die obstructing body on. The abdomen is usually distended because, 
owing to the obstruction, both gas and fluid accumulate above it — the 
distension will therefore be most marked when the obstruction is low, 
and least marked when the obstruction is higher up. Vomiting occurs — 
at first the patient vomits stomach contents and then later, as the intestine 
becomes distended by the fluid accumulating in it above the obstruction, 
this fluid is regurgitated into the stomach and the stomach expels it by 
vomiting. When this happens the vomiting therefore becomes regurgitant 
in character; it is effortless and large quantities of brown fluid are brought 
up. CkiUapse is marked. 

The history usually elicited is that the bowels acted at the beginning of 
the illness but not since, and if the patient has taken any aperients he will 
usually say that they cither failed to act or that he vomited after taking 
them. The nurse should also try to discover whether the patient knows 
if he has passed flatus or not, as in complete intestinal obstruction flatus is 
not passed. 

(c) Perforation. As a rule the stomach or duodenum is the site of per- 
foration resulting from a peptic ulcer, but any part of the hollow viscera 
may pierforate from other causes. 

Symptoms. The pain in perforation is distinctly localized, sharp at first 
and frequently described as agonizing, and afterwards continuing as a 
severe burning pain. Vomiting may occur at the outset, probably induced 
by the severe pain. Collapse is very marked; the injury to the peritoneum 
following perforation, when the contents of the hollow viscera enter the 
cavity and irritate the membrane, gives rise to a profound degree of 
collapse and prostration; the temperature remains subnormal for several 
hours, then a reaction sets in, the temperature rises somewhat, the degree 
of collapse becomes slightly relieved and the patient is a little warmer or 
better. It is for this reason that surgeons may sometimes wait for an hour 
or so after a case of perforation has been admitted before they operate. 
In perforation the abdomen is characteristically rigid, it is not usually 
distended but on the other hand appears flatter than normal; the muscles 
are contracted and show a characteristically hard boardlike rigidity. 

The preparation for an emergency operation should be as slight as 
possible, and it is important to remember that the first nursing duty is to 
provide the conditions which will tend to reduce the production of post- 
operative shock. The patient should be very carefully and gently hanmed, 
moved with care and quietly placed into a warm bed and lightly but 
adequately covered, be made as comfortable as possible, and reassured 
that his wellbeing is the first consideration of everybody. If, as so fre- 
quently happens, he tends to lie on his back with his knees flexed, a knee 
pillow should be inserted; if the bedclothes appear to lie heavily on his 
tender distended abdomen they should be supported by a low bedcradle. 
For coldness of the extremities, either an electric cradle or electric blanket 
or hot water bottles should bemused, but when the latter are employed 
they rnust be thoroughly well protected as a patient in a yery severe state 
of collapse has lost a great deal of his ability to feel. If dyspnoea is present 
the paaent should have several pillows, otherwise it is advisable to keep 
him as recumbent as possible. 



656 COMMON GENERAL SURGICAL CONDITIONS 

Some patients, owing to the Iknited movement of the painiul abdomen, 
tend to lie with the arms above the head in order to assist the movements 
of the chest in breathing. In this case a bed jacket with long sleeves 
should be employed to protect the arms and keep them warm. 

Pending the arrival of a doctor the patient must not be given anything 
by mouth, but his mouth should be cleaned and his lips moistened. The 
nurse should use every available opportunity during the waiting period 
in order to promote the reaction which may be expected after the initial 
condition of shock, and a very large part of her preparation of the patient 
for operation is the irnfauvement of his general wellbeing, which is best 
carried out by the provision of rest and warmth, maintenance of his 
general comfort and reassurance in order to avoid, or at least decrease 
the degree of shock which must of necessity follow the operation which 
is to be performed. 

Handling of the patient as regards preparation should be as light as 
possible: In some cases shaving and preparation of the skin of the abdomen 
may be possible; in others, to whom the slightest touch gives pain, this 
must be left until the patient is under the anaesthetic. A. specimen of 
urine ought to be obtained and tested for acetone, sugar, and albumin. 

Aperients and enemata should never be given unless sj>ecially ordered. 
In some cases, where vomiting is persistent, the doctor may wish to wash 
the stomach out before an anaesthetic is given and the nurse will be 
expected to prepare for this. As a rule, a pre-operative injection of 
morphia or atropine, or of both drugs, may be ordered. 

ACUTE APPENDICITIS 

Symptoms. The symptoms of acute appendicitis include pain, usually 
of sudden onset, at first generalized over the whole abdomen and later 
becoming localized to the characteristic site of appendicitis, i.e. McBur- 
ney’s point, situated midway between the umbilicus and the anterior 
superior iliac spine. The patient complains of nausea and in some cases he 
vomits; the temperature may be slightly raised and the pulse rate quick- 
ened, ^ough these are not invariable; the abdomen is rigid and tender, 
tenderness being particularly marked over the right iliac fossa. 

The pre-operative care described on p. 630 is carried out as a routine 
measure. In emergency cases the full preparation is not possible as the 
patient may be t^en almost directly to the operating theatre. 

After the operation the wound is usually closed — unless the peritoneum 
is involved, when some form of drainage tube will be left in. 

Post-operative nursing care. On return from the theatre the patient 
will be placed recumbent in bed with one soft pillow for his head and a 
knee piUow to support the thighs. If there is a fair degree of shock it is 
usual for a rectal saline to be given. If the patient has drainage tubes in the 
abdominal cavity, he is pdac^ in Fowler’s position as soon as he is round 
from the anaesthetic in order to facilitate drainage and to prevent the 
complication of abscess formatiem; otherwise, he will be nursed recumbent 
with two or three pillows supporting head and shoulders. 

The ordinary routine care of a patient under an anaesthetic is carried 
out. As soon as vomiting has ceas^ he may be given fluids, light fluids 
being continued for two days followed by a light farinaceotis diet. An 



ACUTE APPENDICITIS 657 

aperient is administered on the second or third night, and after the bowels 
have acted the patient may have ordinary diet. A flatus tube should be 
p^ed whenever necessary to relieve abdominal distension. The knee 
pillow ought to be taken out on the fifth day and the patient encouraged 
to move. 

Dressing. If the dressing is simple, it is merely necessary to keep it 
covered in order to protect it from the bedclothes either by means of 
elastoplast or by a bandage. On the fifth or sixth day any Michel’s clips 
should be removed, and Ae rubber tubing which has been placed under 
the tension sutures should be cut, these sutures being removed about the 
tenth or twelfth day. When the dressing is complicated by the insertion 
of drainage tubes it requires to be attended to fairly firequently, the wound 
being redressed and repacked and the drainage tubes removed as soon as 
they cease to be effective. In a straightforward case they would be re- 
moved in two or three days. 

An average case of simple appendicectomy will get up about the 
twelfth day and be discharged from hospital on the fourteenth day. Cases 
in whom a mid-line incision is necessary get up about the sixteenth or 
seventeenth day and are discharged at the end of 3 weeks. 

The complications to be feared in the post-operative nursing care of 
acute appendicitis include peritonitis, abscess formation, faecal fistula, 
and pleurisy and empyema occurring on the right side. 

OPERATIONS ON THE STOMACH 

Partial gastrectomy, gastro-duodenostomy and gastro-enterostomy, are the 
operations commonly employed on the stomach. These are usually 
undertaken in cases where medical treatment has proved unavailing in 
extensive peptic ulceration; and also in cases where the patient has been 
the victim of repeated bleeding (haematemesis) ; in cases where perfora- 
tion has occurr^ and in others where marked scarring and contraction 
has rendered the stomach unable to fulfil its normal function. 

In gastro-enterostomy communication is made between the stomach and 
intestine; in gastro-duodenostomy it is between the stomach and duodenum; 
in partied gastrectomy the ulcer-bearing area of the stomach is removed, 
that is, the pyloric end. All these operations are followed by considerable 
shock; in the last-mentioned case shock is probably most serious. 

Preparation. The usual preparation for operation is carried out; in 
addition, it is important for the stomach to be quite empty and therefore 
the last feeding should be given 6-8 hours before operation. It is necessary 
to prepare a very large area of skin. 

Post -operative mirsing care. The patient is received into bed re- 
cumbent with a pillow underneath his knees. The foot of the bed is 
elevated on 18-inch blocks, an electric cradle is put over the body and, 
unless the surgeon wishes a blood transfusion to be ^ven, it is usual to 
rive the patient either continuous rectal saline or subcutaneous saline 
tat the first 12 hours. 

The patient b carefully watched. His colour is noted, his pulse is taken 
half-houriy, his abdomen is watched for distension and ^e dressing for the 
oozii^ of any serum; it is also important to keep the binder firmly applied, 



658 COMMON GENERAL SURGICAL CONDITIONS 

the amount that the patient vomits should be careiully noted and reported. 
He may be allowed to rinse his mouth out as soon as he begins to conse 
round, and his Hps should be moistened with water; as soon as vomiting 
ceases, even as early as from 6-8 hours,- he may be given half an ounce of 
water occasionally — about every hour, perhaps. 

The condition of shock should be very carefiilly noted, and after 6 or 8 
hours, if the condition is satisfactory the foot of the bed may be gradually 
lower^ putting it on to la-inch blocks for 3 hours, then on to 6-inch 
blocks and then omitting blocks altogether. The patient should then 
gradually be raised into a sitting position; he may be given one pillow 
each hour until he is sitting erect, supported on four pillows in Fowler’s 
position; the knee pillow should adjusted and the patient’s arms sup- 
ported so that he is comfortably resting. 

As it is very important for the patient to receive an adequate amount of 
fluid the continuous rectal saline may be continued beyond 12 hours. In 
cases in which the patient is able to t^e a little more fluid by mouth con- 
tinuous administration may be omitted and replaced by the administra- 
tion of 10 ounces of saline every 4 hours. It is important that the flatus 
tube should be passed before a salme is given, and throughout the whole 
post-operative period observation must be made for abdominal distension 
and notice taken of any abdominal discomfort. When abdominal disten- 
sion is marked it is usually treated by the administration of a turpentine 
enema. 

In many cases after the first 1 2 hours the patient may be able to take an 
ounce or an ounce and a half of water, every hour or hour and a half, 
and by the second day this may be increased to 2 ounces; by the third or 
fourth day he may be able to have regular feedings of 2 ounces of water 
and I ounce of milk every 2 hours. The milk should be citrated and the 
feedings strained. By the time the patient is taking 3 ounces of fluid every 
2 hours the salines may be decreased to every 6 hours instead of four- 
hourly. The amount of fluid taken by mouth may be gradually increased 
until, by the fifth or sixth day, the patient may be having as much as 5 
ounces every 2 hours — three parts of milk and one part of water. 

By the end of a week the value of the food may be increased and the 
same quantity of pure milk, beef tea, Benger’s food, or arrowroot may be 
given. There is no need to strain the feedings now, but the nurse should 
see that they are not lumpy, and by this time the salines will have been 
omitted. Between the e^hth or tenth days, according to the condition of 
the patient, the amount of fluids may be increased and the diet also 
increased imtil the patient is having egg and milk, egg custard and a little 
pounded fish. Between the eleventh to me fourteenth day it may be further 
increased, and the patient may be given milk pudding, potato and gravy, 
thin bread and butter and a little minced chicken occasionally. After a 
fortnight he may be having frirly ordinary diet but red meat should be 
restricted to fresh mutton given once or twice a weeL 

The bowels re(|uire a certain amount of careful regulation. As already 
stated, a turpentme enema wiU be employed after tiie first twenty-four 
hours for the relief of flatulence if necessary. From the second day on- 
wards, until the fourteenth, a small enema is given daily to evacuate the 
bowel, but after the fourteenth day the patient is given liquid paraffin 
and phoiolphthalein twice daily, and the bowelB are r^;uiated in this 
manner. 



OPERATIONS ON THE STOMACH 659 

The stitches arc usually removed between the tenth and twelfth day, 
and the patient may get up between the eighteenth and twentieth day 
if the co^ition has not been complicated. 

HERNIA 

A hernia is a protrusion of an organ into the walls of the cavity in which 
it is contained. The term is most often applied to herniae of the abdominal 
cavity, which occur most frequently in one of three situations: (a) Inguinal 
hernia, through the inguinal canal, having its exit at the external abdom- 
inal ring just above the groin; {b) Femoral f which exists by means of the 
crural canal at a point below the groin, and (c) Umbilical, protruding at 
the side of the umbilicus, the type most commonly occurring in infants 
and in persons of weak abdominal musculature such as fat, middle-aged 
women. 

It will be seen, therefore, that a hernia occurs at what is naturally a 
weak spot in some part of the abdominal wall. A hernia consists of a sac, or 
lining; in the instances given this is peritoneum — the coverings of the sac, i.e. 
the abdominal wall, and the contents which in this case wiU omentum 
and fat, and occasionally a portion of gut. 

The operation undertaken is radical repair of the hernia, the weakened 
parts being darned or patched with strips of fascia. 

Post -operative nursing care. Many surgeons like a firm roller band- 
age applied to secure the dressing and to give some support. The patient 
is nursed in a recumbent position with one or two pillows, a knee pillow 
to support the thighs and an air ring to relieve pressure on the lower 
part of the back. The diet should be fluid at first, or very light solids, 
until the bowels have been opened. An aperient is mually given on the 
second night after operation; clips are removed on the fifth day and 
stitches on the tenth day; but, in cases where Michel’s clips are the only 
suture used, alternate clips are taken out on the fifth, and the remainder 
removed on the sixth day. 

The patient is usually allowed to get up about the sixteenth or seven- 
teenth day and discharged from the hospital on the twenty-first day, 
except in the case of umbilical hernia in which the time of getting up and 
of discharge are both delayed for a further week. 

HAEMORRHOIDS 

Haemorrhoids, or piles, are varicose veins in the region of the rectum 
and anus. They are external when on the skin, and interned when on the 
mucosa of the lower part of the rectum. As in all cases of varicose veins 
there is possibly a congenital tendoicy to this condition, but predisposing 
causes of haemorrhoids are numerous and varioiB, such as long hours of 
standing and walking, straining at stool with constipation, the presence of 
abdominal and pelvic tumours, and congestive heart disease and diseases 
of the liver. Any or all of these conditions may be the cause of congestion 
of blood in the haemorrhoidal vdns and will predispose to their dilation. 

Symptoms. The symptoms are bleeding on defecation and prols^e of 
the piles, which in time will become thrombosed and the parts aftroted 
ulcerated. 



660 COMMON OSNSRAL SUROIOAL CONDITIONS 

Treatment. In the palHaHve inatmmt constipation must be considered 
and treated and the prolapsed parts kept very clean, and astringent and 
soothing, and even anesthetic applications employed for the rdhd'of pain. 
Injection treatment is undertaken for suitable cases of internal piles. Operation 
is performed in other cases and in some where injection treatment has 
been unsuccessful. 

Pre-operative treatment. In addition to the pre-optative treatment 
already described on p. 630, certain special measures have to be con- 
sidered in the preparation of cases of haemorrhoids. If possible the patient 
should be in hospital 2 or 3 days before operation. Two days beforehand 
an aperient should be given followed by an enema; one day before the 
operation the enema should be repeated. Some surgeons older another 
rectal wash-out 12 hours before the operation, others do not. The diet 
preparatory to operation should consist of non-residue foods. 

Post -operative nursing care. If the patient has had a general 
anaesthetic and not a spinal, he will be put back into bed recumbent, 
with one pillow under hu head, and he should be given a knee pillow and 
an air ring. During the first 4 days the diet wiU consist of codl fluids, and 
in addition some opiate mixtiure will be given, such as tinct. opium 10 
minims, twice a day in order to delay peristalsis and prevent the patient 
fiom having his bowels moved for several days. As soon as the bowels arc 
opened he may have light diet such as fish. 

The most important point in the care of these cases is the attention to the wound 
and dressing. The patient will return from the theatre with vaseline gauze 
packed around a large rubber tube about 4 inches long which has been 
placed into the ano-rectal passage; a piece of silk thread or fine string 
will be stitched into the distal end of this tube and this string will be 
arranged outside the dressing and kept in position by a piece of vaseline 
gauze. Unless the patient bleeds it is usual to leave tto tube in for from 
2 to 4 days. If the vaseline gauze becomes displaced before this time it may 
have to be renewed. Preparatory to removing the tube the patient is given 
6 ounces of olive oil through the tube, the bed being elevated on blocks; 
the patient is given a fairly large dose of castor oil about the same time 
and if the bowels do not act wi^n a reasonable time this is followed by a 
simple enema also administered through the tube. When the bowels act 
the tube comes out. In some cases the tube may come out earlier, and some 
smgeons like to replace it, while others order vaseline gauze to be packed 
into the cavity until the enema is given. Once the bowels have been opened 
the patient is allowed to get up to the bath t-wice a day, and after each 
bath the wound is syringed with eusol, vaseline gauze b^g packed into 
the cavity; this treatment is also carried out after every act of defecation. 
Subsequently the bowels are kept acting by an emulsion of liquid paraffin 
and phenolphthalein given as required. 

The second great difficulty the nurse will probably encounter will be 
retention of urine. These patients are fi%quently distre:»ed by the inability 
to pass urine and the nurse will have to use all her ingenuity by alteration 
of position (as described on p. 405) in order to effect relief. In rare cases 
it will be found necessary to t^e the tube out while the patient passes 
urine, a firsh tube being replaced and the dresring attended to imme- 
diatdy afterwards. Catheterization should not Im resorted to unless 
specially requested by the surgeon. 



RESECTION OF COLON 


66 l 

RBSEGTION OF COLON; COLOSf OMY; PERINEAL 
EXCISION OF RECTUM 

Resection of cidon in which a portion of gut is removed and an end to 
end anastomosis performed, is undertaken when there is a large amotmt 
of destruction of a part of this organ such as may occur in diverticulitis, 
in caicinoma and in rare cases of paralytic ileus. The post-operative nursing 
care is similar to that of any other acute aMominal condition and the special 
observations and precautions have ail been described on pp. 636 to 644. 

Colostomy. Colostomy is an opening into the colon by which its con- 
tents can be made to discharge on to the surface of the body. This con- 
dition may be made permanent in cases of excision of the rectum, and in cases 
of inoperable growth. It is performed as a temporaty measure before operations 
of abdomino-anal excision of rectum when the colon is anastomosed to the 
anus, thus retaining the sphincter. It is also performed as a temporary 
measure before operating on some removable growth, and therefore may 
precede or may be associated with resection of the colon, in such cases 
the colostomy is termed a ‘safety valve’, and is only maintained until heal- 
ing occurs. A Paul’s tube is inserted into the colon, the tube sloughs off in 
about five days as the wound heals, and secondary suture will be employed 
if necessary to assist healing of the wound. During the time the contents of 
the bowel are draining and until the wound is healed it should be irrigated 
with a mild antiseptic and kept very clean in order to promote healing. 
The surrounding skin should be protected with some form of grease. 

When a colostomy is performed with intent to be more permanent in 
character, a portion of the gut is brought out on to the surface and kept 
in position by means of a glass rod, which is usually retained for about 
10 days. After the operation the nurse should see that the patient is wear- 
ing a firm binder and, as the colon is stitched to the subcutaneous tissues, 
movement ought to be avoided. The stitches on each side of the colostomy 
should be protected wdth antiseptic and covered with elastoplast in order 
to prevent their being soiled with the discharge from the colostomy 
opening; it is possible to wash the elastoplast when soiled, but it should 
not be remov^ until the tenth day when the skin sutures will be taken 
out. 

The colostomy may be opened at the time of operation, but some 
surgeons will leave this for 3 or 4 days. When the skin stitches are removed 
on the tenth day the elastoplast protecting the skin may be removed and 
the skin washed with soap and water. The glass rod is now removed and 
usually replaced by a small piece of rubber tubing which will be kept in for 
a further period of 4 days. The skin will be again covered with elastoplast, 
and the easiest way to do this is to cut a window through which the colos- 
tomy will protrude, having the elastoplast adherent to the skin all round. 
Once the rod has been removed colostomy wash-outs commence, and 
these may be carried out by the use of an ordinary Higginson syringe with 
a catheter attached, the wash-out being given into the proximal end, at 
the same time each day, usually early in the morning in order to educate 
the bowel to be emptied at a convenient time each day. If the abdomen 
is distended at any time a flatus tube may be passed into the colon through 
the proximal opening. In cases of emergency colostomy an olive oil enema, 
given via the proximal opening, may be required to start the faeces flow- 



662 COMMON OKNS&AI. SUKOtOAL CONDITIONS 

ing. In cases when the rectum is not closed or obliterated and will serve 
as an opening, a wash-out is, given into the distal end of the colostomy 
and, the patient sitting on a bedpan, the wash-out will be returned 
through the anus. This measure is employed in order to keep the lower part 
of the bowel clean and free of mucus. 

The elastoplast application already described will be used until the 
rubber tube which h^ replaced the glass rod is removed; this is taken 
away on the fourteenth day and afterwards the patient may be taken to 
the bath. At this period the patient is supplied with a belt. There are a 
variety of belts on the market, and it is a good plan to have one lined with 
jaconet and to have the part over the colostomy slighdy stiffened in order 
to prevent fiiction. The patient is now taught how to put his belt on and 
take it off, and also to wash his colostomy out daily either by means of a 
Higginson’s syringe with a catheter attached or by using a catheter and 
tubing and irrigation can. 

Perineal excision of rectum. This operation is only undertaken in 
the presence of inoperable growth involving the rectum. As a rule a 
colostomy is performed some time beforehand, at least 14 days — and 
longer than that if the condition of the patient is poor — in order to give 
time for improvement before such a large and serious operation is under- 
taken. The blood urea content is investigated and the urine very carefully 
tested. As the patient will suffer from a good deed of shock it is usual to 
give him a blood transfusion either before, during or after the operation. 

The usual preparation for operation is carried out; presuming that the 
operation is to take place at ten o’clock next morning, the last food will 
be given at night, but the patient may have barley sugar after this. 
Early the next morning the colon will be washed out as usual, the sur- 
rounding skin painted with an antiseptic solution and the colostomy 
covered with oiled silk and strapping in order to seal it during the opera- 
tion. In a female patient the vagina would be douched, and both male 
and female patients would be catheterized a short time before the opera- 
tion and have a self-retaining catheter left in. 

Post -operative nursing care. This is a large operation and as the 
patient will suffer serious shock he should be received back into bed in a 
recumbent position and have the foot of the bed elevated on 18-inch 
blocks. He may have been given a blood transfusion in the theatre and 
this may be repeated afterwards; otherwise it is usual to give fairly large 
quantities of subcutaneous saline — up to 2 pints. The patient is kept as 
warm as possible by the use of electric cradles. After 36 hours the foot of 
the bed is gradually lowered, being put on to 12-inch blocks first, then on 
to 6-inch blocks and finally lowered to the floor. As this patient must not 
be distuihed for anything during this period of grave post-operative shock 
through which he is passing, the catheter is left in for two days, or some 
form of suction bladder drainage is employed. The patient is nursed in 
the recumbent position with two pillows and an air ring. As soon as vomit- 
ing ceases he should be given fluids by mouth, as mucm as he can take, so 
that he may be hydrated by this means and then subcutaneous saline or 
other artificial provision of fluid may be omitted. As soon as the patient 
feels he would like it he may be given light diet and he should have at 
much fluid and food as he can take in order to effect improvement in his 
general condition as rapidly as possible. 



RESBCTIQN 09 COLON 663 

Care of the dressing. The patient will have returned from' the operat- 
ing theatre with a roll of vaseline gauze and two corrugated rubber drain- 
age tubes about 6 inches long inserted into the wound and incorporated 
in the dressing on each side. This drainage tubing will be removed about 
the third day, a little at a time amd, as the dressing is very painful, morphia 
is cdien ordered to be given when it is disturbed. The cavity should be 
kept loosely filled with vaseline gauze — ^the tube may inadvertently be 
puUed out when the gauze is changed but it should be put back, freshly 
sterilized pieces being used. The tubing is now gradually shortened, and 
unless the stitches slough, which often happens, they should be taken out 
about the sixth or eighth day, and as soon as they are out an attempt 
should be made to keep the buttocks together by putting elastoplast across 
them in order to compress the anal region and facilitate healing. Once the 
original pack is out the cavity should be irrigated and repacked three 
times a day, or as often as is necessary to keep it clean. The bowels are 
acting regularly by means of the colostomy opening. As soon as the 
patient’s condition will permit it, usually after die fourteenth day, he is 
taken to the bathroom in a wheel chair and sits in a warm bath for lo, 
20 or 30 minutes in order to soak the dressing, which is then removed and 
the wound irrigated. As the wound becomes cleaner the vaseline gauze 
is replaced by an antiseptic dressing — such as one of the many aniline 
dyes — which will stimulate healing. 

THYROIDECTOMY 

The pre -operative treatment of patients for the operation of 
thyroidectomy is usually undertaken in a medical unit. The medical care 
of these cases has already been described in the section dealing with the 
disorders of the endocrine organs, on p. 433. It is sufficient here to 
state that the principles of treatment include an attempt to get the basal 
metabolic rate at the lowest level to which it can be brought; frequent 
teats are carried out and at the same time the patient is given graduated 
doses of Lugol’s iodine. It is very important for the nurse to realize that 
the patient requires to be frequently reassured, that his co-operation is 
necessary for the sticcess of the treatment, and that he should be brought 
to look upon the operation and the effect he will obtain from it with fear- 
less confidence. In many instances the patient is not informed of the actual 
day of operation but is informed that it will take place in a day or so; 
then, for example on the morning of the day of operation, after a good 
night’s sleep the patient will be warned that it is to take place in an hour 
or two. 

The type of anaesthetic used varies with the tvishes of the surgeon: 
if gas and oxygen arc employed the patient will have an early breaMast; 
if a local anaesthetic only is to be used the patient may have a cup of 
tea a couple of hours after breakfast and h^ a glass of water an hour 
before the operation. 

Throequarters of an hom: beforehand, the usual pre-operative drugs 
are admi^tered. In these cases omnopon is employed in preference to 
morphia, a J grain is given combined vdth atropine i/iooth grain. The 
patient is prepared fer the theatre and placed on the stretcher on his bed, 
he passes urine and has all other points attended to (see p. 630). When a 
loccd anaesthetic cmly is used the drugs given three^uarters of an hour 



664 COMMON OENERAI. SURGICAL CONDITIONS 

before the operation may be | of a grain of omnopon and 1/130^ ctf a 
grain of scopolamine. A second dose of omnopon J of a grain is given in 
the theatre waiting room. 

Post-operative nursing care. The position in which the patient is 
received in bed depends on whether he has had a local or a general 
anaesthetic: in the former case he may be placed in whatever position he 
likes, either having one pillow to support him or several pillows; if a 
general anaesthetic has been employed he will have to be nursed recum- 
bent until he regains consciousness. The pulse must be taken and recorded 
every half hour for the first 12 hours. The respirations tend to slow down 
to as low as eight a minute — this must be very carefully watched and, 
if they get below twelve, an administration of oxygen containing carbon 
dioxide 7 per cent, should be given by the nasal route until the respirations 
are increased in depth and frequency up to 18 a minute. The pulse should 
be carefully noted, as irregularity and rapidity may occur and any tachy- 
cardia should be reported. This should also be noted upon the chart. 

Two of the most important points in the care of cases after thyroid- 
ectomy arc to make them swallow a drink of water and speak as soon as 
jjossible, as they are likely to be afilictcd by fear of being unable to use 
the throat for these two purposes which if not rectified at the outset may 
become an obsession. The nurse will notice that when she gives them a 
drink it has to be carefully administered, since the patient will choke and 
splutter and cough, and she must encourage and reassure him, knowing 
that he can swallow, and she should give him small drinks at fairly fre- 
quent intervals until he can accomplish this feat with comparative case. 

Another important point to be remembered is that these patients 
perspire a great deal. This must be expected and warm dry clothing should 
be provided and warm towels for rubbing the patient down. The adminis- 
tration of fluid is another important point. On return to the ward they 
will frequently be given a rectal saline containing glucose up to 2 pints; 
this may be continued until the next morning, by which time the patient 
should be able to take drinks very freely and in this way to get sufficient 
fluid. 

The complication most to be feared is bleeding. The pulse will be an 
indicadon of this and the nurse must be on the look-out for the symptoms 
of bleeding characterized by a blanched skin, a weak, rapid, thready, 
irregular pulse aind shallow breathing. Bleeding from a superficial vessel 
will soak through the dressing and can be seen, and the dressing can be 
changed; but in some cases the bleeding may come from a vessel deep in 
the tissues of the neck and the patient may bleed seriously before this is dis- 
covered. An observant nurse should be able to nodee the filling up of the 
tissues of the neck in the form of a swelling in the area of the gland. 

The dressing of gauze and wool is maintained in position by means of a 
piece of strapping which is brought over crosswise from the back and 
crossed on each side of the breast; it maintains the dressing in position 
without applying pressure as would a circular bandage. In cases of vomit- 
ing the patient should be supplied with a jaconet bib long enough and 
wide enough to cover the whole of the operation area — this is tied round 
the neck by tapes attached to the jaconet, care being taken that it is not 
tied tightly. 

Womd. On the first or second momii^ afio* the pperatiem the dressing 



THYROHXBOTOMY ^5 

is teyken down and the drainage tubes removed. The surgeon taikes a great 
interest in the perfect adhmon of the margins of the wound in order to 
ensTU^ an excellent cosmetic result. On the second day, if Michel’s clips 
have been used, alternate clips are removed and the remainder arc taken 
out on the third day. When sutures are employed the horsehair sutures 
are removed on the fourth day and silkworm-gut stitches at the end of a 
week. When clips are being used no dressing is employed after the fifth 
day, and a little lanoline is rubbed into the skin very gently in order to 
render it soft and pliant. 

The patient in a satisfactory case is usually allowed up about the tenth 
day, and should have a basal metabolic rate test carried out before dis- 
charge and as a rule goes home between the twelfth and fourteenth days. 

OPERATIONS ON THE BREAST 

Operations on the breast include opening an abscess, removal of ade- 
noma, simple amputation of the breast when it, only, is removed, leaving 
muscles and glands intact, and radical mastectomy performed for carcinoma. 
In this case large skin flaps are turned back and the breast, fascia, muscles 
and lymphatic glands are removed including dissection of the axillary 
group of glands. The skin flaps are then turned over and sutured together; 
in some cases they will not meet and a large exposed area may be left. The 
surgeon may perform a skin-grafting operation at the time of operation 
or wait to perform it later; but he does not as a rule attempt to pull the 
edges together as this would result in tension, and sloughing of the flaps 
might occur. 

After simple amputation of the breast one or two drainage tubes are put in 
at the lower border where drainage is likely to be free, and owing to the 
extensive removal of the tissue there will be a good deal of oozing during 
the first 48 hours. A large dressing is put on in order to absorb the exudate 
and discharge, and the arm is placed in a sling before the patient leaves 
the theatre. 

Pre-operative treatment. Routine pre-operative measures are carried out, 
but a very large area of skin should be prepared as the area of ojseration 
is extensive. In addition an area of skin on the outer aspect of one thigh 
should be prepared in case the surgeon wishes to perform a skin-grafting 
operation. 

Post -operative care. There arc three main points to be considered in 
the post-operative nursing care of cases of radical mastectomy', the first is 
that shock will be very marked owing to the exposure of the large area 
and fairly extensive amount of bleeding, and the other two considerations 
arc intelligent care of the dressing and re-education of the movements of 
the arm. 

The patient will be received back to bed in a recumbent position, 
the arm will be in a sling and should be supported by pillows; if the 
patient is a heavy woman she should be given a knee pillow. 

Shock will be treated by external applications of warmth by electric 
cradle, electric blankets, or hot water bottles. Many sisters provide small 
blankets to drape round the patient’s shoulders and have the bedgown 
and bedjacket ready warming in a hot chamber to put on before the 
patient leaves the operating theatre. As a rule a rectal saline will be 



^ COMMON OBNSIUI. iUltOlKlAl. OONOmONS 

administered and rqpeated in 4 hours if required. It iuav not he required^ 
as although than cases suffer IBrom a good deal ofhutial shock dbey ropond 
rapidly to treatment 

Dremitf. From the outset the dresnng should be carefully watdbed for 
bleeding and> if it comes through, it should be repacked; it should not be 
redress^ during the first 12-34 hours unless the bleedii^ is more cxteruive 
than might reasonably be expected. 

The dressing should be changed on the first day, and the nurse should 
move the rubber drainage tube slightly in order to prevent its adhering 
to the flaps; the flaps should be very carefully inspected to see if they are 
ballooning as the result of serum beneath them; if this occurs the nurse 
should cru^ully insert a pair of sinus forceps at the side of a stitch at the 
most dependent part of the incision near the medial line — the drainage 
tubes will usually have been inserted at the lower border of the incision 
on its lateral aspect. When attending to the dressing she should also inspect 
the edges of the wound for any sign of sloughing and should note whether 
there appears to be undue tension, as this wUl invariably result in slough- 
ing. 

On the second day the tube is usually removed. Throughout the whole 
of the post-operative period in her care of the dressing the nurse will make 
the observatioiis described above and deal with them as they arise. As soon 
as possible she will encourage healii^ by the applications of an astrigent 
drying powder such tts aristol, and in an uncomplicated case continuous 
sutures would be removed alraut the seventh or eighth day, clips alter- 
nately on the fifth and sixth day, and tension stitches between the tenth 
and fourteenth days. 

In many instances radium will be employed, a number of tubes being 
inserted — ordinarily three containing 10 milligrammes and one containing 
5 milligrammes are used. These are usually left in for 48 hours and are 
then removed (see care of patients wearir^ radium, p. 792). 

Care of the arm. In many instances the arm will be put in a sling in the 
theatre as already stated; if so, it should not be put into the sleeve of the 
bedgown but should be supported at the side of the body with pillows. 
Some surgeons like their patients to use their arm from the very first, 
though others do not allow the arm to be disturbed for the first 3 days. 
In all cases it is important for the nurse to see that the movements of 
abduction and external rotation are performed several times a day as 
these are the movements which are important to a woman in doing her 
hair, and fastening her clothes at the back. 

It is very important that the patient shall be able to perform such 
movements before she leaves the hospital. In uncomplicated cases the 
patient will get up about the iiilh day with her arm supported in a sling, 
but she should be encouraged to take it out and use it occasionally, and 
if the wound is healed the patient may go out as early as the fourteenth 
day. 

The con^ications which are most commonly met with are bronchitis, 
broncho-pneumonia and thrombosis. 

SURGERY OF THE THORAX 

ThoraC(HE*fosty is removal of a number of ribs which results in collapse 
of the chest wall and consequently in collapse of the lui^. It is performed 



ftOKOBRY 09 THE THO&AX 667 

in puktumaxy tobercnlosis, empycxaaand bronchiectasis. Before operation 
the patient sliould be as well as possible. 

In order to obtain the best results, a highly skiMed team of surgeons, 
physicians and nurses are required both in the operating theatre and in 
the rccovay ward. Further, the patient should know the object and 
extent of the operation, and as the op>eration will be perfomud imder a 
local anaesthetic he should be able to play his part by intelligent co- 
operation with the nurse and anxiesthetist in attendance. The patient 
may have to be removed to a hospital for this operation, although many 
modem sanatoria are equipped for this purpose. If the patient can be in 
the environment he is used to, this is an advantage because he feels he 
is amongst trusted firiends. Moreover the morale is usually high in a 
sanatorium where patients are confident of the success of the operation 
owing to experience in the success of it in others who have undergone 
the same operation. 

The skin of the back requires very careful preparations, any acne or 
pustules should be healed before the operation. The patient is placed on 
his side on the operating table and comfortably steadied by sandbags. 
A large J-shaped incision is made extending between the spine and the 
scapula, the scapula is lifted off the chest wall and held firmly out of 
the way by suitable retractors. 

As the operation will be performed in stages (usually 3 stages), the 
3 upper ribs are generally removed at the first stage, then two to three 
we^ later, the next three or four ribs are removed and the remaining 
ones at a subsequent operation. The ribs to be excised are well exposed, 
and denuded of their periosteum. Special attention is paid to cutting 
through the ribs as near the vertebr^ ends as possible so that the pul- 
monary collapse finally produced may be as complete as possible. As 
the incision made is an extensive one, considerable bleeding occurs. 
Moreover very large muscles are incised and the loss of blood and muscle 
traiuna results in considerable shock. 

The surgeon works swifdy and skilfully. Bleeding points are sealed by 
cautery. The wound is sutured without drainage, but great care is 
exercised in excluding all serum from beneath the skin so that healing 
may take place without sepsis intervening. This is important as the 
original wound will have to be re-incised for the subsequent operations. 
The gauze and wool dressing is strapped in position by means of elasto- 
plast but no turns of strapping or bandage may encircle the chest, as 
tlte movements of respiration must be encouraged and not impeded. 

Post -operative care. The patient is put carefully back to bed sup- 
ported by pillows and in such a position that the movements of the sound 
side of the chest arc not interfered with. The position adopted depends 
a great deal on the general condition of the patient and also on the post- 
operative routine measures prescribed by the surgeon. The patient may 
be placed flat in bed with the foot raised on blocks until his pulse is 
satisfactory. To assist pulmonary drainage in cases where the patient 
finds expectoration a difficulty this position may be maintained for 
several days. Alternatively on returning fix>m the theatre die patient 
may be propped up on pillows and placed on his affected side. Although 
he is suffering from a good deal of shodk he will be (juite able to follow 
any instructions given him and will be interested m the progress he 



668 COMMON OBNERAL SURGICAL CONDITIONS 

makes. His position should be chsmged at frequent intervals as move- 
ment will help to stimulate coughing and eiqjectoration. He may have 
been given a blood transfusion in the operating theatre. This will be 
repeated as required. It is essential that ^e patient should have plenty 
of fluid, he will be able to take some by mouth; the amount can be 
supplemented by the administration of fruid by other routes. 

At least 5 to 6 pints of fluid must be administered daily by mouth, 
rectum, subcutaneous tissue or vein during the first few days. The patient 
may complain of nausea at first, but as soon as possible he should be 
given sm^ drinks of water, tea, and fruit juice every 15 minutes. The 
amount he can take should ^ gradually increased. As soon as the patient 
wishes he may have solid food, this should be of high calorie value and 
have a high vitamin content. If the patient is nursed in his cubicle, this 
will be closed at fust and the temperature of the room kept at about 
68° to 70° F. For the first 24 to 48 hours or until he has recovered 
fix>m shock the patient must be kept warm. He must not be subjected 
to draft or chilling. Ordinary sanatorium temperature cannot be con- 
sidered safe until several days have elapsed. The pulse rate or volume 
should be watched and recorded every 15 minutes at first, and then 
every hour. The temperature should be taken and charted regularly. 
The amount of fluid given (by all routes) should be carefully recorded. 

Drugs will be given to relieve ^in but consideration must be made as to 
the effect of su 5 i drugs on the respirations and cough reflex. Pain and 
shock tend to diminish the cough reflex. Morphia further inhibits it. 
Small doses of sedative drugs given at regular intervals are recommended. 
The patient should be kept free fium discomfort but the cough reflex 
should not be affected by the sedatives given. It is important that the 
p>atient should cough frequently, at least every hour. 

As the result of rcmovJil of ribs the lung collapses and the walls of 
cavities in the lung which contained secretion are brought together. 
This results in the secretion being squeezed out and it must be coughed 
up, otherwise it will lodge in healthy bronchial tub^ and cause fresh 
tuberculous lesions. 

Difficulty in expectoration can be relieved by hot lemon or lime juice 
drinks or sipping hot sodium bicarbonate solution. It may also be stimu- 
lated by steam inhalations. 

The amount of sputum should be charted by weight or volume. Rattling 
in the air tub« ^ows they want clearing and if the fluid secretion can- 
not be removed by effective coughing aided by j>osture the surgeon 
will suck out the collection of fluid by means of a bronchscope. 

The patient must be encouraged to cough at regular intervals, at least every 
hour during the days immediately after the operation and the cough 
must result in the bringing up of sputum. Various measures have been 
devised to encourage a patient to cough. The nurse standing on the 
patients sound side should get him to sit forward and placing one arm 
across the fix>nt of his chest give support with the flat of the hand to the 
lower part of the wound, at the same time she supports the back of the 
chest with her other hand. Thus supported the patient will cough. Or 
she may stand on the affected side with the flat of one hand over the 
lower part of the woimd and the other hand on the front of the chest. 
She must never be content with feeble attempts at hawking but must 
see that coughing is effective. The patient should take a few deep breaths 



SURGERY OF THE THORAX 6S9 

and then cough. The value of effective coughing cannot be over-emphasized 
for the reasons given above. At the end of a period sjjent in coughing 
the patient should rest. Oxygen is given if necessary to relieve respiratory 
distress. It is usually administered by means of a B.L.B. mask (see p. 322). 
to ensure that the patient is given a fairly high concentration of the gas. 

The wound will be dressed when required. As a rule it is carefully attended 
to the morning after the operation, though it may be necessary to change 
the dressing earlier than this. It is important to ^ep the wound edges in 
apposition and to press out, from beneath skin flaps and wound edges, 
any serum resting there. The skin is usually painted with some antiseptic. 
Iodine, alcohol or an aniline dye preparation may be used. After the first 
day or two the wound may not need to be disturbed until the stitches are 
removed in 7 to 10 days. The wound and stitch marks are then kept clean 
and free from scabs, because, as already mentioned, the original incision 
will be used again in performing the next stage of thoracoplasty in 2 or 
3 weeks’ time. 

Complications which may occur and which pre- and post-operative care 
go far to prevent include local sepsis and haematoma which may cause the 
wound to break down. 

Spread of tuberculous infection to adjacent bronchi has already been men- 
tioned. Scoliosis may result but it b preventable. 

As the result of removal of ribs the normal aligxunent of the trunk is 
interfered with and stability can only be obtained by re-education. This 
work is principally in the hands of an experienced physio-therapist but 
the nurse shoiild make it her business to know the aims of treatment so 
that she may co-operate. It is important for example that the patient 
should learn to lie and sit upright, to have his head in a straight line 
with his trunk. The movement of the arm and shoulder girdle should be 
practised. A patient should be able to elevate his arm above his head as 
in arm stretching upwards, within a fraction of the movement possible 
on the soimd side. Provided that these points are attended to and that the 
patient learns to lie, sit and walk with his head straight, shoulders 
squared and head in line with the trunk scoliosis will not occur. As the 
aim of treatment is to restore the function of the lungs as fully as possible 
breathing exercises are taught to encourage movement of the chest and 
expansion of the lungs. .A clever physio-therapist can teach patients to 
expiand diflferent portions of the lung indicating the area to be expanded 
by placing the hand over the area upon which the patient is to concen- 
trate. Localized breathing can be made an interesting occupation. 

Pressure by means of weights and sandbags is applied to the parts of 
the chest firom which the rite have been removed, particularly the upper 
parts, over the apex and in the axilla, in order to ensure that collapse 
of the limg will be as complete as possible. New rite grow fixtm the 
periosteum which was stripped off the ribs removed at the time of 
operation. They will grow in a new position. The rite of a patient who 
has had Aoracoplasty performed can be described as lying in the posiflon 
of a bucket handle which lies against the edge of the bucket placed 
on its side, and not, as in the normal chest, where the rite correspond in 
position to the handle elevated from the side of the bucket. 

AJUr Care. After thoracoplasty a patient requires a period of fitun three 
to six montte* rest in bra. Etering this time breathing exercises and 



670 COMMON GENERAL SURGICAL CONDITIONS 

exncises which aim at maintaining good posture the head and 
shoidders in relation to the trunk are taught and practised. The ultimate 
result as regards posture and absence of deformity dq>end8 on this treat* 
ment. After a period of rest in bed the patient is allowed to get up and 
finally he is sent to a sanatorium for graduated exercise treatment until 
he is considered to be ready to take up some employment. He will spend 
approximately six months in the sanatorium. 

A patient who has had thoracoplasty performed should keep in touch 
with his surgeon or hospital for about two years so that the condition 
of his chest and his general state of health may be observed. In many 
instances there will not be any retiun of the disease and the sound paits 
of the lung or lungs will assume the work of the entire lungs. Such a 
patient may consider himself a normal individual, who has however 
had a long illness and undergone a major operation, 

Lobectomy is performed in bronchiectasis and in some cases of 
abscess of the lung. It is usually performed under a spinal anaesthetic. 
The chest is opened, a portion of rib is removed, and through this opening 
the diseased lobe is severed from its attachments and the stump sutured. 

Before operation the patient is taught how to breathe and how to 
empty his chest of air. He has been subjected to a long course of postural 
dreiinage treatment in order to have the lung as free of pus as possible. 

In order to make the pleural surfaces adhere togtihxx poudrage is carried 
out several weeks before operation. A pneumothorax is performed and 
a thorascope is passed, through which a special powder is blown on to 
the surface of the visceral pleura. Talc containing an antiseptic is em- 
ployed, this is irritant to the lung and causes the two pleurae to adhere 
and by this means the lobes of the lung which are not removed at the 
operation arc prevented from collapsing. 

Post-operative care. Treatment for shock will usually be necessary and 
a blood transfusion may be required. But as soon as possible the patient 
should be propped up in bed as he must be encomaged to cough up 
.secretion or pus. There will be a drainage tube in the wound in the 
ch^t and as air must never be allowed to enter the chest cavity, this 
tube will be attached to a special drzunage apparatus so that intrapleural 
negative pressure is maintained. Breathing exercises will be given and 
the patient may be allowed to get up after 2 to 3 weeks. 

X-ray examination is carried out to observe the rate of expansion of 
the remaining lobes of the lung which, if all goes well, will soon fill the 
chest cavity. 

Complications which may arise include haemorrhage fi'om the stump 
or fiom an intercostal vessel. Collapse of the lung may occur but the 
formation of adhesions between the pleura and the maintenance of 
intrapleural negative pressure aim at preventing this comj^cation. 

Pneumonectomy is removal of a lung which is performed for carci- 
noma and in some cases of bronchiectasis when the lung is very fibrous. 
The limg is collapsed before the operation by means of a pneumothorax 
partly to accustom the patient to breathing vrith one lung and thus 
minimise his post-operative di^omfort. Before operation the patient 
should be in as good a general state of health as possible. 

Post-operatioe Care. The patient needs the same care as described after 
thoracoplasty. Shodc must be treated and a blood transfusion is usually 



SURGERY or THE THORAX 67 1 

needed. Complications include sepsis which gives rise to a good deal 
of exudation. Haemorrhage may occur. 

Rib resection is performed for the relief and drainage of empyema 
(see p. 375). From to 3 inches of rib are removed, the pleural cavity 
is opened, carefully inspected, pus and clots are removed, the cavity 
is irrigated and a flanged tube, such as Tudor Edwards’s is inserted and 
the wound is sutured. 

Post-operative Care. In many instances this operation is performed under 
a local anaesthetic so that the patient is able to be propped up on pillows 
as soon as he returns to the ward. The first consideration is to maintain 
drainage of the empyema cavity. A tube, usually Tudor Edwards’s tube 
which is a combined drainage and irrigation tube is employed. This 
tube is attached either to a simple underwater drainage bottle or a 
suction drainage apparatus. It is very important to see that the tube 
does not get kinked; it is equally important to ensure that no air enters 
the cavity. Dressings around the tube and over the wound should be 
maintained in position by pieces of elastoplast. The chest should not 
be encircled by any turns of bandage or binder. 

The day after operation pleural irrigation will be started. No force 
may be employed, fluid either saline, boracic or Dakin’s solution will 
be gently run in to the cavity by means of a tube and funnel. The small 
bore tube on Tudor Edwards’s tube is employed for this so that the 
fluid returns through the larger tube. The empyema cavity vriU head 
slowly as the lung expands slowly so that the drainage tube should not 
be omitted too soon. The depth of the cavity may be investigated by a 
fine gum elastic bougie and the tube shortened as necessary at intervals 
of about a week. Breathing exercises should be taught. 

The danger of empyema is that it may, even after operation and 
drainage, become chronic. To prevent this, drainage should be efficient 
and the daily irrigation of the cavity as complete as possible, breathing 
exercises will assist expansion of the lung. 

A patient who has had an empyema for some time will be very toxic, 
he may be considerably wasted as he has had a grave toxaemia. He 
needs fresh air and goed food, interest and recreation, as he needs en- 
couragement in order to face the difficulties of life again. 

Minor operations on the thorax (pneumothorax, pneumoperitoneum, 
phrenic crush and avulsion, and thoracoscopy) have been mentioned on 
p. 494 where pulmonary tuberculosis is dealt with. 


SURGICAL AMPUTATION OF A LIMB 

Amputation is only employed when all attempts to save a limb in case 
of injury or disease have failed. A limb amputated is a deformity which 
may upset the balance of weight and give rise to deformity of the ^ine. 

In the post -operative care of a patient with the leg amputated above 
the knee, a divided bed will be used (see p. 79). The bedclothing is so 
arranged that the stump c<m be seen. A tourniquet should be in readiness 
in case of bleeding and the nurses in the ward should know how to apply 
it. Bleeding is not very likely to occur, but should this happen the patient*8 
life will be in immediate danger and unless those on duty can act he will 
bleed to death in a few minutes. The nurses should be warned of this possi- 



672 COMMON OBNERAL SURGICAL CONDITIONS 

bility, warned not to be frightened and told exactly how to act if this 
emeigency arises. 

The stump will be supported by a sandbag covered by jaconet and a 
st<Nile towd, for the first few days after operation. There will be consider- 
ate oozing of serum, and a drainage tube or tubes will have been inserted. 
TTie gauze and wool should be changed as often as necessary. During the 
dressing of the stump it should be firmly held, as it will jump and tibiis is 
distressing to the patient. Particular attention should be paid to the skin 
flaps, in order to observe whether serum is collecting beneath them and 
to effect its removal. 

After the first few days the sandbag which is supporting the stump will 
be removed and it should then lie flat on the b^. It is important to 
see that the bed does not sink in the middle as the possibility of flexion 
occurring at the hip joint has to be remembered, because any flexional 
deformity would have to be corrected before the patient could use an 
artificial limb with comfort. 


OPERATIONS ON THE GALLBLADDER 

Inflammation of the gallbladder or cholecystitis has been described on 
p. 394. In surgical treatment the gallbladder may be opened and drained, 
choUcysiotomy, or it may be removed, cholecystectomy. Before an operation is 
undertaken the function of the organ will be investigated by means of 
cholecystography. 

Vitamin K which controls the prothrombin content of the blood and 
maintains it at the level required to give normal coagulation time is often 
given to cases of obstructive jaundice for several days before operation in 
order to prevent post-operative bleeding in jaundiced patients. KapUon is 
the synthetic preparation recently produced by the Glaxo laboratories. 
The dose is from i cc.. to 2 c.c. by hypodermic injection for several days 
before and several days after operation. 

In the post -operative nursii^ care the patient is propped up into 
Fowler’s position as soon as he recovers from the anaesthetic in order to 
aid the action of the diaphragm and so prevent the complications of hypo- 
static pneumonia and abdominal distension; and also to facilitate drainage 
from the wound, and avoid any possibility of retention of bile in the 
abdominal cavity which might give rise to sepsis. Vomiting, which 
may last for some hours, and a fair amount of abdominal distension, 
arc the discomforts which prove troublesome after the operation of chole- 
cystectomy. Small drinks of hot water containing sodium bicarbonate 
may be sufficient to relieve vomiting, abdominal distension may be re- 
lieved by passing a flatus tube or it may need the administration of a 
carminative enema. An aperient should be given as soon as possible, 
within 24 to 36 hours after the operation, and when the bowels have acted 
the patient may be able to take light diet. 

The dressing should be watched, a drainage tube or glove drain is in- 
serted as there may be oozing from the liver and leakage of bile for a few 
days. 

The instnments required for some of tiie emotions mentioned wUl be seen 
on pp. 661-688. 



SKIN ORAFTINO 


673 


SKIN GRAFTING 

Skin grafting is the transplanting of skin from one area to another in 
order to cover a part which is denuded of skin, either as the result of 
injury as in burns, or to reduce deformity such as for example may result 
from scarring. Skin grafting was introduced by Reverdin in 1869. It now 
fonns a most important part of plastic surgery. 

Types of Graft. The pinch graft which was Reverdin’s original method 
consists in pinching up small pieces of skin, separating them by means of 
a knife and transferring them to a raw area. The pinch grafts vary in 
size from that of a ladybird to a postage stamp. They are dotted over the 
area to be covered. 

The Thiersch graft consists of larger pieces of skin which may be thin or 
thick grafts according as the graft needs to be adapted to the surface 
on which it is to be placed. This form of graft is taken by means of a 
special razor. 

Wolfe's graft. In this graft the whole thickness of skin is taken. It is 
dissected out, denuded of fat and subcutaneous tissue and applied to the 
raw surface for which it is intended. It may be stitched in position. 

Dermatome graft is a term used to describe a graft taken by means of a 
special cutting instrument, a dermatome. By this means long strips of skin 
can be removed. These grafts are usually taken from the area of the 
abdomen or from the back. 

Pedicle graft. This method is used when it is required specially to ensure 
that the graft retains a good blood supply. The skin is raised and sutured 
tubular fashion. It is left attached at each end and dressed without pres- 
sure and avoiding all tension. After a period of about two weeks, provided 
that all has gone well with the graft, one end of the pedicle is detached 
and implanted on to the area to be grafted. This part of the body is then 
fixed to the donor area until the gr^ has taken and is receiving a good 
blood supply. Then, supposing for example, the area to which this graft 
is to be applied is a scar; the scar is excised, the pedicle is detached from 
its second end, the tube-like structure is unrolled and spread out and laid 
on to the area to be grafted. 

Preparation for skin grafting. Speaking generally only autogenous 
grafts are successful. If sometimes grafts from other individuals are con- 
sidered, it is important that the donor and recipient shall be of the same 
blood group. 

The donor area of skin and the area to be grafted receive the same pre- 
paration. The skin is cleansed with a weak solution of dcttol, about 10 
per cent, and then with saline. In the operating theatre the same solution 
of dettol is used and the skin is cleansed with ether in addition. When a 
mucous surface such as the nose is to be included in the area to be grafted 
a very weak solution of mercury is sometimes employed. 

Dressing skin grafted areas. The donor area is dried with sterile 
swabs, covered with tulle gras over which a compress of saline is put. 
This is firmly bandaged on and finally the bandage is either secured by 
some adhesive substance, or by strapping in order to ensure that the 
dressing remains absolutely immobile. 



674 COMMON OENBRAl. 8URO10AL CONDITIONS 

The ^afUd area is covered with tulle gras and saline commvsses, or 
altemativdy with cotton wool soaked in flavine and paraffin. This dress- 
ing is covered by gauze wrung out in saline and finally bandaged and 
fir^y secured as in the case of the donor area. To render immobile the 
dressing applied to a skin grafted area is a most important nursing point. 

Pressure. The surgeon wiU indicate what degree of pressure is required. 
In some cases when considerable pressure is needed a form of plasticine, 
known as stent is employed. The graft laid over the specially cut and 
prepared piece of stent is applied to the area to be covered. 



Chapter 43 

Common Surgical Conditions of the Genito-Urinary 
Tract, including Points in the Preparation and 
Post-Operative Care 

Surgicd conditions of kidn^s and bladder: pyelitis, acute suppurative nephritis, 
stone in kidney — Operations on the kidn/y — Stone in the bladder — Operations on the 
bladder — Enlargement of the prostate gland, special measures in preparation for 
operation and post-operative nursing 

I nvesrigation of the genito-urinary tract includes: 

Chemical examination of the urine; 

Microscopic examination of the urine; 

Bacteriological examination; 

Examination by direct X ray; 

Examination by pyelography. 

These investigations have been described in the sections dealing with 
the examination of urine, and investigations and tests (sec pp. 59 and 
212). 

SURGICAL CONDITIONS OP THE KIDNEY AND BLADDER 

Surgical diseases of the kidney may be classified under three head- 
ings: (1) injury to the organ, which may cause serious haemorrhage and 
necessitate removal, (2) congenital abnormalities, the commonest of which is 
the horseshoe-shaped Wdney in which the lower poles of the organ are 
united by a band of renal tissue passing across in front of the lumbar 
vertebrae, and (3) irfammatory conditions of the kidney. Nephritis, which is 
treated medically, has been described on p. 398. Apart from this condition 
surgical inflammation of the kidney may be either acute or chronic. 

Pyelitis is acute inflammation of the kidney pelvis, it is usually due to 
the presence of bacillus coli. There are a diversity of opinions as to how 
thb organism reaches the kidney. Many surgeons think it is due to direct 
infection of the organ fi'om the colon which lies in firont of it and, as in 
many instances only one kidney is infected, it b thought that infection by 
means of the blood stream b comparatively rare. (For description of symp- 
toms and treatment see Pyelitis, p. 402.) 

Acute suppurative nephritis. Thb condition b quite distinct firom 
the acute nephritis treated medically (see p. 398), and b due to organisms 
which may have reached the kidney from some septic fociu, su<^ as an 
infective skin lesion, especially carbuncle. 

The syn^toms are pain in the loin, and tenderness over the aflected 
kidney accompanwd by a rise in temperature. The pain may be vary 
acute and may be mbtaken for an acute attack of appen^dtb. As 
the disease progresses pus forms, and will be found to be present in the 
uriiM. 


675 



676 THE GENITO-URINARY TRACT 

A chronic it^ammatory condition of the kidn^ may also occur, probably due 
to tuberculosis. The symptoms in these cases are similar, but less acute 
than those described above. 

Stone in the kidney. A stone in a kidney is an accumulation of salts, 
normally present in urine, which have formed a concretion. It occurs most 
commonly when the urine is highly concentrated. The substances of 
which these stones are fonned arc calcium oxylate, which forms the majority, 
and uric acid, urates and phosphates. The stone begins to form in one of the 
tubules and, as it gets larger, it forces its way into the pelvis of the kidney, 
and may remain diere, gradually increasing in size or, if it is very small, 
it may pass down the ureter and may even reach the bladder and be 
passed out in the urine. 

The complications of stone in the kidney are (i) blockage of the ureter, which 
may cause renal colic (see below); (2) hydronephrosis, which is due to dam- 
ming the urine back on to the kidneys which results in damage to the 
kidney substance. When a kidney is filled with urine the condition is 
termed hydronephrosis. If this stagnant urine becomes infected, which is 
very likely to happen, it gives rise to a kidney full of pus — pyonephrosis. 

The symptoms of stone in the kidney vary — Acre may not be any at all, 
if the stone grows slowly and does not move. On the other hand there may 
be pain in the loin, owing to irritation of the kidney substance by pressure 
or movement of a stone. When definite symptoms arise there is pain in 
the loin which is made worse by activity. Haematuria may be present, 
movement of the stone into the pelvis of the kidney and ureter gives rise 
to renal colic, characterized by attacks of acute pain in the loin, passing 
round to the side of the abdomen and shooting down to the groin. It is 
cramplike in character, causing the patient to roll about in agony. His 
skin becomes covered with cold sweat and he vomits. He has an uncontrol- 
lable desire to pass urine, and passes a few drops at a time every few 
minutes. This condition is described as strangury. An attack usually lasts 
for several hours, and it may subside or can generally be relieved by 
morphia. 

A complication of a stone in the ureter is impaction, riving rise to hydrone- 
phrosis, because the urine is pent back on the kidney and, if infection 
occurs, the condition proceeds to one of pyonephrosis. 

The treatment is removal of the stone. 

Operations on the kidney. Nephrectomy is removal of the kidney. 
Nephropesy is stitching the kidney to the posterior abdominal wall. Nephro- 
tomy is opening into the kidney, usually performed for the removal of stone 
and in this case the term nephrolithotorry may alternatively be employed. 

In the preparation for operations on the kiSi^ the renal function is thoroughly 
investigated as described in the case of prostatectomy. It is important that 
the patient should have one healthy kidney before removal of the second 
kidney — ^which may be a diseased organ — is considered. The general pre- 
paration is as described for any other abdominal operation. It is important 
to prepare a large area of skin back and front. 

In the post-operatioe nursing care considerable pain and shock will need to 
be reliev^. The complications which constitute the greatest danger in these 
cases are secondary haemorrhage and suppression of urine. The patient is put 
in Fowler’s position as soon as possible. The dressing is care^y observed 
for bleeding. A drainage tube will usually have inserted, and the 



SUROtCAL CONDItlONS OV TltE KIDNEY 6^^ 

drasing will be taken down after 24 hours and the flaps examined for 
the presence of fluid beneath them, particularly on the anterior aspect of 
the wound. The margins should be inspected to see that overlapping does 
not occur. The drainage tube will be removed in 2 or 3 days as the quan- 
tity of serous discharge lessens. The stitches zire usually removed after 10- 
12 days. 

The pulse should be observed every half-hour, as bleeding may occur. 
Blood may collect in the tissues, or it may move from the kidney to the 
bladder, and be passed in the urine. The urine should be measured and 
inspected for the amount of blood, which ought to decrease as the days go 
by. Until the urine is free from blood it is very important that the patient 
should lie quietly and not make any exertion. The administration of 
bland fluids in large quantities in order to maintain the activity of the 
renal tract is imf>ortant. 

Stone in the bladder. A stone may form in the bladder or it may 
form in the kidney and, passing into the bladder, lie there and increase 
in size. The symptoms are pain when jolted, and on passing urine. As the 
bladder empties during the act of micturition its walls contract on the 
stone, pressing it down against the most sensitive part of the bladder which 
is the urethral opening, and causing great pain. As the bladder fills again 
the pain is relieved. Stone in the bladder is usually accompanied by some 
haematuria which may be slight or severe. 

Surgical treatment is removal of the stone, either by opening the bladder 
from above — suprapubic cystotomy — or by removing it via the urethra. 

Operations on the bladder. In addition to the operation for removal 
of the prostate gland; operations may be undertaken for the removal of 
growths or stone from the bladder. The same preliminary investigation, 
preparation and after care are needed as in the case of prostatectomy. 

Removal of stone may be carried out by means of an abdominal opening, 
above the pubes, suprapubic cystotomy, or the stone may be crushed and the 
particles evacuated by the operation of litholapaxy when an instrument — a 
lithotrite — ris passed into the bladder by the urethra, as in passing a cathe- 
ter; the stone is grasped between the blades and crushed, the particles 
being evacuated by means of a special instrument — Bigelow’s evacuator, 
and the bladder is irrigated. The post-operative nursing care includes observa- 
tion of the character of the uririe pass^ and the administration of copious 
bland fluids in order to flush the urinary system. Bladder irrigation and 
urinary antiseptics may be ordered. 

The position and size of the stone is previously investigated by the use 
of a cystoscope which is described in the notes on the investigations of the 
cavities of the body on p. 214. 

Urethrotomy is the cutting through of a dense mass of tissue in the urethra 
which is acting as a stricture, causing obstruction and retention of urine. 

An instrument called a lurethrotome is employed; it is a slender rod 
curved like a male catheter, having a thread at its tip on to which a filiform 
bougie can be screwed. A small groove on the upper or anterior aspect of 
the urethrotome carries a specially devised knife with a triangular shaped 
blade, which can be slipped along this groove and used to divide the 
stricture. It is very necessary to keep this kmfe sharp, and it should be oiled 
when put away and the instrument carefully cleaned. 



678 THE OENITO-URINARY TRACT 

Enlargement of the Prostate Gland occurs in elderly men. In many 
cases this enlargement is phyidological; in others it may be due to cardnoma, 
but recent research into the relationship of sex honmnes to thr cause of 
cancer has led to the discovery that carcinoma of the prostate gland can 
be successfully treated by the oral administration of a synthetic prepara- 
tion of oestrin — stilboestrol. The history obtained and the symptoms present 
vary. There may have been frequency of micturition for some time, urine 
dribbling away day and night, the bladder always containing some resid- 
ual urine which may, and frequently does, result in cystitis. On the other 
hand, the first indication of prostatic enlargement may be acute retention 
of urine or an alarming attack of haematuria. In most cases there is some 
degree of renal ineflBciency. 

Treatment is operative. Prostatectomy is performed, but before it can 
be undertaken certain preliminary investigations are carried out, including 
estimation of the blood pressure and blood urea content, urea clearance 
and urea concentration tests, cystoscopy, and examination of the teeth, 
and investigation of the condition of the heart and lungs. 

Preparation for Prostatectomy. Whether the operation is performed in one 
or two stages, and whether treatment of the bladder needs to be carried 
out before operation, depends on the presence of urinary infection and the 
degree of renal efficiency. By the two-stage operation suprapubic cysto- 
tomy is first performed and the bladder is drained by means of a self- 
retaining catheter, and bladder irrigation is carried out twice a day for 
about 10 days. Alternatively, bladder irrigation only may be utilized or 
continuous bladder irrigation and drainage employed (see also bladder 
drainage p. 142). Irrigation is carried out as follows: A weak solution of 
potassium permanganate, pale pink in colour, is first employed until the 
fluid is returning clear and clean, and retains its pink colour, which shows 
that all decomposable material has been removed. Sterile water is then 
used, the bladder is emptied, and finally, four ounces of 1-3,000 solution 
of nitrate of silver are injected and the catheter is clamped for half-an- 
hour (if the patient can tolerate so long). The clamp is then removed and 
the bladder allowed to drain into a bottle at the bedside. 

General preparation. An aperient is given two mornings before operation 
and liquid paraffin three times a day; an enema is given during the after- 
noon of the day before operation— this may be repeated if necessary. The 
skin of the abdomen, penis, scrotum, the upper half of the thighs, and the 
buttocks and loins is prepared and a sterile dressing is bandaged dn. 

Prostatectomy may be performed by various methods. The gland 
may be enucleated with the fingers through an incision in the wall of the 
bladder, a large drainage tube is put in and the patient wears a Hamilton- 
Irving’s apparatus until the wound heals and he begins to pass urine 
naturally. 

Harris's Prostatectomy is frequently the op>eration of choice. Immediately 
before this operation the urethra is syringed with 1-5,000 oxycyanidc of 
mercury. The surgeon makes a horizontal incision four inches long, incises 
the bladder, and with the first finger of his left hand (on which he is wear- 
ing two rubber gloves) in the rectum, and two fingers of his right hand in 
the bladder, he enucleates the gland with his fingers. The prostatic 
urethra is reconstructed and all bleeding stopped, a whisde tip catheter is 
passed in through the urethra, a silkworm gut stitdi is passed throu^ Ihe 



SUROlCAt. CONDITIONS OF THE KIDNEY 679 

eye of the catheter and brought out through the abdominal wall to which 
it is secured by the special button shown in fig. 239, p. 700. The blazer 
is dried and closed, a small corrugated drain is inserted between the 
layers of muscles (this is taken out on the second day). Michel’s clips 
are used to suture the skin, amd these are removed on the fifth day. In 
some cases a small suprapubic catheter is inserted. 

With a I -ounce Canny Ryall syringe the surgeon now washes out the 
bladder with boradc lotion, and when the solution is withdrawn clear he 
allows the catheter to drain into an 8-ounce bottle. The patient is now 
taken back to the ward. At the end of the operation the vas deferens is tied 
on each side to prevent epidymitis. 

Post-operative care. The bladder drains into a bottle beside the bed. The 
patient is given a sedative, cither morphia gr. J or J grain of omnopon. 
After 8 hours he is propped up in Fowler’s position. He is given fluids for 
12 hours and may then have light diet. He must drink many pints of 
fluid a day both before and after operation. An aperient is given on the 
second evening and liquid paraffin is given three times a day. An enema 
should never be given without the permission of the surgeon, as it may 
cause bleeding. Drainage from the bladder must be observed carefully, 
drainage must be maintained and the amount measured. If the catheter 
should appear blocked, i ounce of sodium citrate solution (2 per cent.) 
may be passed gently into the bladder and withdrawn; diis may be 
repeated, if it is not efficacious the condition must be reported to the 
surgeon. If the catheter appears to have slipped out of the bladder, gentle 
traction on the button to which it is attached may result in drainage being 
resumed. The end of the penis and the portion of the catheter which may 
have slipped out should be carefully cleansed with peroxide of hydrogen 
before it is drawn back into the uredira. 

It is very important that the bladder should not be distended, and if 
these measures fail to re-establish drainage the surgeon should be notified; 
if he suspects that the bladder contains bloodclot he may inject i ounce 
of glycerine of pepsin which will dissolve the clot. After half-an-hour it 
may be possible to wash out the bladder, using a Canny Ryall syringe 
and injecting and withdrawing i ounce of the sodium citrate solution until 
the fluid is clear. 

On the tenth day zifter Harris’s prostatectomy the silkworm gut stitch 
which is holding the catheter is cut and the catheter thus freed is taken 
out. The patient may then get up, he may be permitted to have a bath 
on the thirteenth day and may go home towards the end of three weeks, 
about the eighteenth day or so. 

Endoscopic resection is the operation of choice, when the age and general 
medical condition of the patient or the state of the prostate contraindicates 
other measures. From 4 to 8 grammes of the prostate are removed by an 
endoscopic electrode, the bladder is washed out, a catheter tied in and 
the patient taken back to bed. The usual post-operative observations are 
made. The bladder is watched for distension which may be treated as 
described in the care after Harris’s operation. The catheter is removed 
about the fifth day. 

Decompression of the distended urinary bladder by means of 
Kidd’s inverted U tube is one of the methods employed of gradually 
emptying a seriously distended bladder. A catheter is fixed into the blad- 



68o THE OENITCK-URINARY TRACT 

der and connected by means of a glass tube to a length of rubber tubing 
which is attached to the shorter of the two Ikubs of the Kidd’s tube. Rub- 


Kidds 



U-Tube suspended at 
irtc. FOR DECOMPRESSION OF 

Urinary Bladder in the Treatment 
OF Retention. 


ber tubing from ^ loi^ limb 
carries imnc syphoned nrom me 
bladder into a bottle at the bedside. 

The Kidd’s tube is suspended at 
the bedside just high enough to per- 
mit a small quantity of urine to be 
syphoned out when the patient takes 
a deep breath; if it is too high no 
urine can escape, and if placed too 
low the contents of the bladder will 
be syphoned off too rapidly. When 
setting up the apparatus the correct 
level is determined by asking the 
patient to cough and when the correct 
level is found a little urine will 
escape. As the bladder is gradually 
emptied it will be necessary to lower 
the tube. The lower end of the tub- 
ing which conveys the urine into 
the bottle at the bedside should be 
above the fluid in this bottle. The 
amount of urine which is syphoned 
off must be carefully measured and 
a record should be kept of the fluid 
the patient takes. He should have 
plenty to drink. 


The instruments required for some of the operations mentioned will be seen on 

PP- G97-700. 



Sutures AND LigaYurcs 


68i 



ill 


I ' a 

m 






fm 


riG. 221. 

Reading from left to right across both figures : — 

(1) Fagge’s towel clipw, 6 pairs; Backhaus’ clips, 4 pairs. 

(2) Retractors: 4 Morris’s, 2 Langenbeck’s, 2 Mathieu’s, and 
3 pairs Durham’s. (3) 2 Bard-Parkcr’s knives. (4) Dissecting 
forceps, 2 plain and 2 toothed. (5) Thomson-Walkcr’s, Mayo’s 
and Kocher’s scissors. (6) i dozen small and large Spencer- 
Wells’s artery forceps. (7) Lane’s tissue forceps: 4 small, 2 large. 
(8) 6 pairs Poirier’s tissue forceps. (9) 2 pairs Moynihan’s gall- 



GENERAL SET OF INSTRUMENTS (A) 



Fig. 222. 

Reading from left to right across both figures : — 
bladder forceps. (lo) 2 pairs Ochsner’s compression forceps, 
(ii) 2 pairs Littlewood’s tissue forceps. (12) Sinus forceps. 
(13) Lane’s, Syme’s and Macdonald’s raspatories. (14) Sharp, 
scoops. (15) Slender probes. (16) Watson-Cheyne’s probe. 
(17) Brodie’s director and winged director. (18) Hooks. 
(19) Aneurysm needle. (20) Ovum forceps. 



GENERAL SET OF INSTRUMENTS (B) AND (C) 

” . ■^!3"'?r'5'>“vS-i.: ' , ■ ■■’TS*Si®«»P53WR»»? 


ml 




1 / 








Fig. 223. — see also Figs. 221 and 222. 

(B) Articles required by Theatre Sister 
(C) Articles required by Ward Sister. 

(B) The theatre sister may be required to prepare ligatures and 
sutures. Here she will need the following (reading from left to 
right) 

Upper Row. Hegar’s needle holder {small size), catgut, tray of 
assorted needles, silkworm gut, silk and thread and two pairs 
small dissecting forceps. 

Below this Row. Reading from above downwards, arc shown: 
stitch scissors, Berkeley’s clip galley (ready charged) and clip 
forceps, and Hegar’s needle holder (large size). 

(C) llic ward sister responsible for the patient will need large 
dissecting forceps, ovum forceps, and scissors for handling dress- 
ings, dabs and swabs. 


685 



Fig. 224. 

Instruments for ArpENDiCECTOMY (minimum requirements). 

(i) Four pairs Mayo’s towel clips. (2) Bard-Parker’s knife. 
(3) I'oothed dissecting forceps. (4) Mayo’s dissecting scissors. 
(5) Plain dissecting forceps. (6) One dozen Spencer-Wells’s 
artery forceps. (7) Duval’s tissue forceps. (S') Aneurysm needle 
with which to thread the appendix stump ligature. (9) Probe 
with which to touch the appendix stump with pure carbolic. 
(10) Durham’s retractor, (ii) Morris’s retractor. (12) Hegar’s 
needle holder. 

In addition, materials for ligature and suture and needles must be 
supplied (see Fig. 220'). 



Resection » Cut «. Colostomy 


686 





Fic;. -{See aLso general wstrimmits, pages G82-4V 
Rcadinja: from left to right: ^ 

Uffek Row. (i) Cosset’s self-retaining abdominal retractor, (2) bistoury, 
(3) hernia director, (4) hernia pusher, (3) hernia needle, (6) liver retractor. 
1a)W'KR Row. (7) Intestinal clamj)s (straight and curved) (2 pairs of each\ 
(8) duodenal clamps (2 pairs), (q) Payr’s crushing clamps (2 pairs). 



CHOLI CYST ECTOMY 


688 




689 







(igi 



T'V .S . 


hypodermic for administration of coramine. 



Fic;. 231. Removal of Semilunar Cartilage. 

(1) Esmarch’s bandage. (2) Scalpels, i for incising the skin and i for 
deeper tissues. (3) Toothed dissecting forceps. (4) Self-retaining retractor. 
(5) Deep-tissue retractors. (6) Spencer-Wells’s forceps. (7 and 8) Mayo- 
Oschner’s forceps. (9) Watson-Cheyne’s probe. (10) Cleft palate knives 
for removal of cartilage. Alternatively a mcningo. 
















'Ml 




' { : ''-'4 




■m 


6.1 7 ! 8.1 a 


Fig. 232. Excision of CiReat Toe joint. 

The great toe joint may be excised in case of hallux valgus (bunion) or hallux 
rigidus.'Fhe instruments, in addition to the general instruments, which may 
be required include: — 

(1) Esmarch’s bandage. 

(2) Mallet. 

(3) Chisel. 

(4) Osteotome. 

(5) Bone cutting forceps. 

(6) Bone nibblers. 

(7) Rougine. 

(8) Sharp bone scorp. 

(9) Bone gouge. 

( lo) Ik)ne brace and burr. 




694 



Fig. 233 . — see paj^es 407-8. 

(i) and (2) arc metal lubes containing hot and cold water for testing 
temperature sense. Callipers for two-point discrimination, cotton wool 
for light touch and pincu.shion with pins for 'pinprick’. (4) Hammer for 
deep reflexes -tendon jerks. (3) Tuning fork for bone and air conduction 
tests. (6) Large tuning fork for vibration .sense. (7) A group of articles for 
examination of the eyes, ophthalmo.scope, eserine and atropine drops, 
rod w ith padded end for roughly testing the visual field, a square of fine 
lawn for corneal reflex and an electric torch for pupil rciiction. (H) Auro- 
scope and aural speculum. (9) Bottles containing different smelling sub- 
stances to test the sense of smell. ( 10) Tape measure. ( i i ) Skin pencil (12) 
A group of articles of different size, shape and texture for stereognosLs. 


695 



Fk;. 234. 

The instruments required for cranial decompression are numerous and 
varied. Cranial surgery is a highly specialized branch. The instruments 
shown above are of the simplest and include:-- 

(A) Rougine. 

(B) Trephine. 

(C) Burr and burr ends. 

(D) Gigli’s saw with handles and Martell's guide. 

(E) Bone nibblers. 

(E) Horsley’s elevator. 

(G) Brain needle. 

(H) Silver clip forceps. 



696 



Fig. 235.-“* page 659. 

Injection and CIaitterization of Haemorrhoids. 

The articles and instruments required include: (i) Haemorrhoidal 
syringe. (2) Haemorrhoidal ring forceps. (3') Haemorrhoidal clamp. 
(4) Electric cautery — this typ>e is commonly employed. (3) Paquelin’s 
thermo-cautery which may alternatively be used. 



697 




698 



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699 



ItRCTHROTOHy: 



Fk;. 238 . — see page 677. 

( 1) Fccvan’s urethrotome with guide. 

(2) Filiform hougics (various sizes). 

(3) Guide with concealed screw for carrying filiform Ixiugies. 

(4) Prostatir catheters, different sizes. 

In addition a local anaesthetic for the urethra, and inak* urethral syringes 
arc shown. 


700 




701 



Fig. 240 . — see page 72 1 . 
Method of Holding a Child 
FOR Examination of the 
Throat. 



Fig. 241 , — see page 721. (1) Light, (2) head mirror, (3) Roger’s spray, 
(4) local anaesthetic and adrenalin, (5) aural speculum, (6) nasal specu- 
lum, (7) aural dressing forceps, (8) nasal dressing forceps, (9) tongue 
depressor, (10) tongue cloth, (i i) post-nasal mirror, (12) laryngeal mirror. 
In addition swabs should be provided, and a spirit lamp for warming the 
mirrors; and maitchcs. 



702 





Fig. 242 . — see pa^e 721. (A) Head mirror, (B) tray containing aural 
specula and dressing forceps, wool in porringer for swabbing (^ar and 
receiver for soiled swabs. 

Articles to test hearing are included: •(!' tuning Ibrk. (D) a('oumet»’r, 
;E) noise lx)x. 



riG. 243 . — see page 721. (1) Politzcr’s bag, (2) Eustachian catheters, 
(3) auscultation tube for use with Politzer’s bag, (4) Siegers speculum. 



703 



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Fig. 248. — see 27G. 

In antrum puncture an opening is made into the maxillary antrum. The 
articles required include: 

(A) Adrenalin, (H) local anaesthetic, iCV) Roger's spray, (D) nasal spe< u- 
lum, (Fd trocar and cannula (2 siz<-s), (I ) cotton wool carrit'is (drc'ssed), 
(G) nasal forceps. 

Articles J or irrigation are show n below : ( 1 ) Higginson's syringe and (2) an- 
trum cannula. A black receiver is su])]>licd so that the presence of pus ran 
< asily be detected. 



7o8 







I’k;, 250 . — see pas,e 728. 

The Position in which a Paiiknt shocld lie after roNsii.- 

LLCTOMY HAS BEEN PERFORMED. 



Fig. 2f,i . — see page 

Showing how the Position illustrated in Fig. 250 is obiained, 








T\G,2-:^Z—^€pager^o. 
The articles required 
for tracheotomy in- 
clude: 


711 



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needles and catgut. 
A sandbag is required 
to place under the 
patient’s shoulders. 









l ie. see l)ai^e 7 ;]o. Every traelKotomy tube 

should 1 m* s('eur<‘ly taped. A sliows the direr lion in 
w’hic h the (‘nd of a ]>ir‘( e (>r tapr*, in whieh a slit has 
b(*en made, is taken throut^h thr* metal slot. H shows 
the lon^ta' end ot the tape rallied through the slot 
in th(* shorter (aid. 



kio. 2')b. see jxi^e 730. C' shows the tilin' taped and 
T< ad\" for use. 



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Fig. 261. Operation for 
Cleft Palate ( inc lucling 
Mr. Denis Browne's instru- 



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Fk;. ‘26.1. Douhlo (l>ilat(’ran 
Harelip with Cilt'ft Palat<‘. 


I’u;. Single (Unilateral) 

Harelip. 



Fh;. 2()5. MocliHt'd Logan’s bow 
used as “d\‘nsi()n Bridge” after 
harelip op(Tation. 



jh(>. A good r<'sull after 
operation for liarelip. ,;\e/r the 
normal pouting" ftosition of the 
mouth. 


Harelip {sec pa^es 



Chapter^ 

Affections of the Ear, Nose and Throat — Harelip 
and dleft Palate — Nursing Care 

Examinatm of ike ear — Syringing an ear — The insertion of drops — Affections of the 
ear: ^ presence of a foreign, body, otitis media and mastoiditis — Affections of the 
nose — Affections of the throat — Tonsillectomy — Intubation — Tracheotomy — Lcayn- 
gectony — Harelip and cleft palate 

T he nurse will frequently be called upon to assist at the examination 
of the ear, nose and throat, and the ^es of case she will be expected 
to nurse in the ward include antrum puncture for drainage of 
sinuses, operations on the nasal septiun, removal of tonsik and adenoids, 
mastoidectomy and, less commonly, tracheotomy and laryngectomy. 

The nursing of ear, nose and throat cases requires keen observation and 
great care, and a good deal of sympathy and thoughtfulness, as in many 
cases the subjects are children and conditions alfecting the nose are par- 
ticularly painful. 


EXAMINATION OF PATIENTS 

The articles needed for the examination of patients in this department 
are shown in fig. 241, p. 701. If the patient is an adult, two firm chairs 
arc required, one for the surgeon and one for the patient who sits opposite 
him. A bell light has been shown in the list of apparatus, but a spot light 
is preferable where this is available. In holding a tiny chUd for examination 
he should be steadied (see fig. 240, p. 701 ) . The nurse should learn to use a 
head mirror and should practise adjusting it; she should learn to look at 
the throat and be able to distinguish the different parts; she should use a 
speculum for examination of the ear and be able to distinguish the drum, 
and she should become familiar with investigation of the nasal cavities, 
using a nasal speculum for this purpose amd being able to recognize the 
septiun, and the inferior and middle turbinate bones. In examination of 
the nose or ear the head must be steady and the hand holding the speculum 
should be steadied against the patient’s head so that if he moves it moves 
with him. 

For a more extensive examination of the ear the ardcles shown in figs 
242 and 243, p. 702, may be required. These include a noise box, tuning 
fork and clapper to test hearing, and eustachian catheters, Politzer’s bag 
and Seigel’s speculum in case the surgeon wishes to test the patency of the 
eustachian tubes. 

Laryngoscopy and bronchoscopy are performed when examination 
of the larynx, trachea and bronchi is to be undertaken. For indirect laryn- 
goscopy some of the articles shown in fig. 241, p. 701 will be needed, includ- 
ing bell light and head mirror; laryngeal mirror and spirit lamp in which 
to warm die glass in order to prevent moisture from condensing upon it; 
local anaesthetic, tongue depressor and a doth with which to hold the 
tongne forward and steady it. 


KK 


yai 



722 the ear, hose and throat 

In direct laryngoscopy the oracles ihown in illustration, fig. 244, p. 703, will 
be needed. The pharynx is cocainized, the mouth is held open, the tongue 
depressed and the laryngoscope passed as fi»r as the opening of the larynx. 

In bronchoscopy a larger instrument— the bronchoscope — is passed 
through the larynx for examination and inspection of fhe tracing and 
bronchi. (Both laryngoscope and bronchoscope ca^ an electric bulb 
which serves to illuminate the passage the surgeon is inspecting.) 

Oesophagoscopy or examination of the oesophagus is performed by 
means of an oesophagoscope (see fig. 245, p. 704). This examination 
is undertaken when it is nec^sary to investigate foe condition of foe 
oesophagus in conditions of stricture or obstruction, or to determine foe 
position of a foreign body or to obtain an estimation of foe changes wblch 
may be occurring in disease of this organ. / 

TREATMENT OP THE EAR 

To cleanse an ear. The nurse may be asked to syringe the ear for foe 
removal of either discharge or wax; or she may be asked to mop foe ear; 
in both cases it is essential that aiier wet mopping or syringing foe ear 
should be swabbed dry and quite free of fluid or discharge. 

A discharging ear. In the care of any patient with a discharging ear it is 
important to observe the type and amount of discharge — a mixture of pus 
and blood usually indicates some acute condition such as acute otitis 
media — a small quantity of thick pus may be coming from a boil in the 
meatus — a quantity of foin muco-purulent or thick purulent discharge fre- 
quently indicates some chronic condition such as chronic otitis m^ia — 
and an offensive discharge may mean that there is some necrosed bone in 
foe middle ezir. 

Patients with discharge should have foe meatus cleaned several times 
a day, drops may be ordered to be inserted and patients should wear a 
little bit of sterile wool in the meatus, but this must be only lighdy packed 
in and should not form a plug, and whenever foe wool is soaked with dis- 
chaige it should be removed and renewed. 

In syringing the ear a special aural syringe (see illustration, fig. 246, 
p. 705) is employed, which can be used withonehand; foelotion used should 
be stciilc and it should be warm, that is, about 99® F.; ifitis cold or hot, it 
may cause the patient to feel dizzy. The patient may be seated on a chair 
or sitting up in bed, a receiver being held beneath the ear and the shoulders 
protected; foe ear should then be inspected, the nurse using speculum, 
light and head mirror for this purpose — she should be able to see the drum 
and note the type and amount of discharge or of wax. She then takes hold 
of the pinna and pulls it in a direction upwards and backwards, and hold- 
ing the syringe places the nozzle in the opening and empties its contents 
into foe ear; foe patient may move slightly, but the nurse follows these 
movements with eare. 

Very gentle syringir^ is necessary in order to remove discharge and 
emptymg foe syringe once may be found to be adequate; but for wax 
more force is necessary, and foe stream of fluid should be focected up to 
foe roof of foe meatus — ^it will then pass upwards and inwards and run 
downwards and outwards along the floor of foe canal. In syiinging fmr 



tRSATUSNT 07 THE EAft 723 

tlie ceoiwal of wax » slightly jerky movement shoi^d be used. After 
syringing the car the patient should be instructed tO' hcdd his head ova: to 
the' ^ie to empty the cansd of fluid. The nurse e^ould dry the meatus 
widi wool, and fbr this fiurpofc wisfw of wool rolled up in the fonn of a 
stidc, or. a wooden stick dressed with wool, or aural dr^ng forceps may 
be employed. 

To insert drops into the car. The patient shotild lie on his side with 
the (*ar to be treated uppermost. The liquid may be drawn up into a 
pipette and the pipette held in a bowl of warm water for a moment or 
two just long enough to warm it slightly, and then applied to the ear and 
the contents gently dropped into the meatus. The patient should keep his 
head in position for fiom 5 to lo minutes, and then turn his head over 
and shake out any fluid that may be left. The ear may then be syringed 
if ordered, or protected by a tiny piece of warm, sterile cotton wool placed 
gently in the canal. 

Drops are frequently employed to soften discharge, and in this case per- 
oxide of hydrogen is used, and this requires special mention as it is neces- 
sary to put in the drops several times at one sitting, emptying the drops off 
by turning the head over and repeating the process until the peroxide has 
ceased to bubble, the meatus being then dried in the ordinary way. 

A mixture of glycerine and sodium biczirbonate is used to soften wax, 
and glycerine and carbolic drops are frequently employed for the relief 
of pain and earache. 

AFFECTIONS OF THE EAR 

Foreign body in the ear. An insect may get into the ear or a child 
may push a small bead or other little object in. An insect may be floated 
out by putting warm lotion into the ear, but if a solid foreign body is in 
the meatus the nurse should not attempt to deal with it as anything she 
does may probably push it farther in and render it more difficult for the 
doctor to remove later. 

Otitis media. This condition may be acute or chronic, and is usually 
due to the spread of infection from the naso-pharynx by means of the 
eustachian tubes. The ^mptoms arc pain, some degree of deafness due to 
blockage of the eustachian tube, a rise in temperature, and increase in 
pulse rate accompanied by headache and malaise. 

When pus forms an abscess may arise behind the drum, and this causes 
the drum to bulge and it may burst, and the contents of the abscess be dis- 
charged; or the condition may be treated by making a small incision in 
order to make an outlet for the dischairge, myringotomy (see fig. 247, p. 706). 
When this is carried out it is important to keep the ear as clean as possible 
by frequently mopping the meatus, and by the application of antiseptic 
drops. As healing occurs the discharge becomes less and the drum eventu- 
ally heals. 

In some cases infection of the middle ear passes to the mastoid antrum 
by the aditus, which is a short passage forming a communication between 
the middle ear and the antrum. 

Mastoiditis. The most prominent symptoms of this condition are pain and 
tenderness behind the ear, and there may, in addition, be thickening and 
swdling owing to the formation of an abbess under the periosteum in this 
region. A rise in temperature is variable but there is always notable quick- 



724 BAR* NOSE. AND THROAT 

cuing of tite pulse rate. It is very imTOitaiit to remember tbat all cases of 
chronic ear oisease can be a cause of mastoiditu. 

Ttu tnt^nent is operative. The usual preparation for operation is carried 
out, sm area of skin over the temporal bone behind the ear and down 
to foe nape of foe neck should be prepared. The meatus and foe pinna 
should be very carefully cleansed. 

In foe post-operative nuxstM care foe patient is received back to bed and 
is placed to lie on foe af]^ted side — ^when he comes round from the 
anaesthetic he will move if it is uncomfortable. The outer dressing is 
changed whenever it is soiled by foe serum oozing through. The wotmd 
will have been packed and the packing will be changed on the second or 
third day after operation. It is a very painful procedure and a general 
anaesthetic is usually employed for this. 

In dressing a mastoidectomy wound the ear must be kept veiy clean, 
and strict asepsis observed. When removing a plug or packing, it should 
first be moistened with warm peroxide of hydrogen and very gently 
removed. When packing the wound ribbon gauze foould be used and it 
should be inserted firmly into foe bottom of the wound in order to ensure 
healing firom foe bottom upwards. As foe wound is very often deep it is 
important to see that foe edges do not curl under. This can be prevented 
by lifting them gently outwards with a pair of forceps and packing foe 
gauze dressing fiimly but gently beacath them so that they rest upon it. 

Complications. Throughout the nursing care observation must be made 
for the possible onset of any symptoms that might indicate foe presence 
of some complication. The most important things to observe are a rise 
of temperature and foe occurrence of rigors, which would suggest foe 
presence of some blood infection or infection of one of the venous sinuses; 
vomiting and headache might suggest the onset of an extradural abscess; 
rigidity and stiffness of foe neck might be the first signs of meningitis, and 
facial paralysis of foe opposite side would suggest a cerebral abscess on the 
affectal side. Other symptoms to be on the look-out for would be a marked 
increase in the pulse rate, the presence of squint, and the onset of drowsi- 
ness and stupor accompanied by an increase in the depth of respiration 
which would indicate an increase in the intracranial pressure. 

AFFECTIONS OF THE NOSE 

Nose bleeding. Epistaxis may occur at any age. The bleeding is 
usually from the front and lower part of the septum, and can therefore 
be controlled by pinching the nose and applying pressure in an upward 
and backward direction towards foe bleeding point. If the bleedii^ con- 
tinues and is noticed to run down the throat it is coming from a point 
farther back and cannot be controlled by pinching foe nose. The treat- 
ment in this case is to pack foe nostrils with gauze and adrenaUn, a piece 
of sorbo, or the finger of a rubber glove filled with wool or gauze. The latter 
is a favourite packing as when it is removed later in does not start foe 
bleeding again. 

Nasal obstruction. The commonest cause of obstruction is abnor- 
mality in structure, and this may be due to fracture of either foe bridge, 
or foe septum, or of both. A fall on the front of foe nose pushes foe s^t 
part backwards and causes defoimity of foe septum — ^marked deviation 
or deflection may block both sides of foe nose. Similar deformity may be 



AI^KCTIOMS OF THE NOSE 735 

due to mal>dev<elopment of die s^tum. General swelling of the naml 
mucous membrane will also give rise to obstruction, and me presence of 
nasal polypi is another cause. 

For a deflected septum, the treatment is operative and submucous resection of 
septum is performed. The preparation includes cleansing the nose, mouth and 
nasopharynx by frequent mouth washes, gargle and nose snifls a day or 
two before the operation. The routine general preparation is employed 
and just before the operation the nose is packed with a mixtiure of cocadne 
and adrenalin in order to prevent bleeding. A nurse should not attempt 
to do this, as it is always undertaken by the surgeon or his assistant. The 
operation may be performed under a local or a general anaesthetic. When 
the septum is removed it is fairly common but not invariable practice to 
insert some form of splint on each side of the mucous membrane of it, in 
order to keep the layers together and prevent the formation of hae- 
matoma between them. These splints may be either gauze plugs, strips 
of green protective, or rubber fingerstalls filled with gauze or wool. They 
are usually kept in for 18-24 hours. In addition a post-nasal sp>onge is 
employed — ^this is a piece of marine sponge with tapes attached which is 
put into the nasopharynx and removed as soon as the patient begins to 
be restless or as soon as the cough reflex returns. It serves the purpose of 
preventing blood from trickling down the nasopharynx into the respira- 
tory passages. 

In the post -operative nursing care the routine treatment will vary 
a little with each surgeon. The patient cannot breathe through the nose 
and therefore it may be necessary to wedge the mouth open and apply 
tongue forceps if the patient is deeply anaesthetized. Most surgeons p>ermit 
the patient to be nursed in bed in a sitting posture, and a few surgeons 
like the patient to get up in a chair as soon as possible. The principal con- 
siderations in the post-operative nursing care are prevention of bleeding 
and sepsis; the patient should be provided with a covered receptacle con- 
taining pieces of gauze which have been sterilized, and he uses these to 
remove any slight moisture from his nose. He may only use one piece of 
gauze once and must then discard it into the bowl provided for this pur- 
pose. In no circumstances may an ordinary handkerchief be used. 

The splints of tubing packed inside the nose are usually taken Out with- 
in 24 hours, and it is a good plan to have a set time for doing this, say 
2 p.m., as this ensures that it shall not be forgotten. Their removal should 
be checked by a responsible person and the fact should be noted on the 
patient’s chart. Six hours later, provided that there is no bleeding, nose 
sniffs may be commenced (see note below). There ^ould be no attempt 
to clean the nose, and it will be found that the sniffs are sufficient for this 
purpose. If any hard clots are present in the nose they may be moistened 
with liquid paraffin and this facilitate separation. 

As a genersd rule the diet should consist of cold fluids and jellied foods for 
the two first days after operation, and then the patient may have ordinary 
light diet, but stimulants should be avoided. Patients who arc kept in 
bed usually like to get up about the fourth day and go home after a week, 
but they should be instructed to move about very cardully as quick 
movements may make the nose bleed. They should be instructed that if 
this happens they must sit quietly in a chair and hold the nose tightly 
between the thumb and finger and apply clean handkerchiefs wrung out of 



73$ TBS XUUf^'HOSB AND THilOAT 

tap water to tl^e upper lip: if tlie bleeding do<s not stop by^ this treatment 
they should sand tor a doctxsr; For the first week or two after returning 
home they must avoid the danger of infection and ^bold therdbre avoid 
all dusty places and thickly populated places, such as cinemas, &c. They 
should also put a litde piece of dean cotton wool in eadt nostril when 
going out of doors for the first 2 weeks. 

Nose sniffs. Any mild antiseptic or an alkaline lotion may be used, 
such as saUhe, sodium bicarbonate solution, &c. A tall glass such as a tooth- 
glass should be employed and the patient should put hh nose into the fluid 
until the opening of both nostrils is covered, and then sniff fluid up the 
nose, and hawk it through in the throat, and spit it out into a reedver. 
It should not be sniffed up to the top of the nose ^ this will cause head- 
ache. 

To Insert drops into the nose a nebulizer may be employed or 
drops may be put in by means of a pipette. The patient sliould lie down 
with the head well back and the drops should be placed into the floor 
of the nose. The patient should maintain this position for a few minutes, 
and may then bring his head forward and shake any fi"ee fluid out of the 
nose, but he should not wipe his nose or blow it. 

To douche the nose, the apparatiis frequently employed is a Higgin- 
son’s syringe, or rubber tubing and funnel, with a nasal nozzle attached. 
The head should be held well forward over a basin and the fluid injected 
with very slight force and allowed to flow gently up one nostril and gently 
down the other. It is important for the patieht to breathe through his 
mouth and he should do this in a conspicuous manner in order to assure 
himself and the nurse that he is breathing. 

Nose blowing. It is important that patients should be taught the 
correct manner of blowing the nose. Take hold of the nose through the 
handkerchief and press on one side only, then blow mucus down the other 
side into the handkerchief, turn the handkerchief and repeat the same 
procedure on the opposite side and repeat the action uiltil the nostrils 
are clean. 

Infection of the sinuses. The nose is so intimately associated with the 
sinuses of the face that nasal inflammation often leads to sinusitis. This 
condition is characterized by very severe pain and marked malaise and 
if the sinuses become seriously infected the general condition of the patient 
will be markedly disabled. 

Antrum puncture. The articles required for this operation are shown 
in fig. 248, p. 707. The opening into the antrum is made near the floor of 
the nose about i j inches from the external opening. The antrum is opened 
and the pus which has collected in it drained out. After this operation the 
nurse will be required to douche the antrum, and as a rule the first douch- 
ing is carried out 24 hours after the puncture and for the first day or two it 
may be found necessary to cocainize the nose before passing the cannula. 

The apparatus used is a Higginson’s syringe and a special antrum can- 
nula (see fig. 248). These are sterilized. Saline, or some other mild 
fluid is used. The patient sits up in bed or on a chair with his head forwwd 
over ia bowl or receiver, the cannula being passed along the floor of the 
nose, its curved point turned outwards, and passed in a <flrection down- 
wards and outwards into the opening made in die wall the anmtm. It 



AivacnoMS 09 the hosb 727 

» comfiarativ^y easy to; pass it, and yet extraordinary how few pec^e 
can do so with confidence, both patients and nurses seeming afraid — ^and 
yet if this canntda is taken in the hand and a half-circle made in a direction 
outwards ird slightly downwards as it is passed, it easily slips into place. 
Once in place it Will be fdt to impinge on the wall of the antrum and the 
4 ull thud which can be felt by gently moving it is unmistakable. The can- 
nula having been inserted, it is then attached to the syringe and the treat- 
ment carried out. It is a very good plan to allow the patient to hold the 
cannula, and it is important to teach him to pass it as he will be expected 
to continue his self-treatment when he leaves the hospital. 

AFFECTIONS OF THE THROAT 

As already stated, a nurse will be frequently called upon to examine 
a patient’s throat and she will often be required to paint the throat. 
Various antiseptic and astringent throat paints will be employed, includ- 
ing glycerine, tannic acid and carbolic. 

To paint the throat she should provide a head mirror, a good light, a 
tongue spatula which ought to be warmed — the rectangular metal tongue 
spatula shown in the illustration on p. 701 is a useful one, a camelhair 
brush being usually employed for applying the paint, and one with a 
curved handle being better than a straight one. A receptacle should be 
provided in which to put the quantity of paint that she is going to use, 
and a receiver for the used brush; a towel may also be required to protect 
the bed or the patient’s clothing. 

With a good light falling on the back of the throat the nurse inspects 
it and makes a mental note of the part she wishes to cover. She asks the 
patient to keep his tongue in the floor of the mouth and puts the tongue 
spatula on it taking care not to get it too far back as this causes the patient 
to gag. She then applies the paint, sweeping it well over the area of the 
fauces and tonsils — trying to avoid the soft palate — and applying it fiirmly 
with confidence and not tickling the patient. 

Gargles. Lotions are frequently used for cleansing the throat, but to 
ensure this they must be retained fairly low down in the throat, and the 
air breathed through the fluid displaces it. As one sister aptly remarked, 
‘gargling is laughing through fluid*. 

Antiseptic gargles such as glycothymolin are employed for cleansing; 
astringents such as solutions of tannic add arc used in the treatment of 
relaxed throat; sedative gargles such as aspirin arc used in painful conditions 
such as acute tonsillitis and after the operation of tonsillectomy. Gargles 
are employed hot or warm. 

Tonsillitis. Inflammation of the tonsils is usually an acute condition; 
in follicular tonsillitis white patches appear on the edge of the tonsil; in 
^arenckjmtatous tonsillitis the substance between the follicles is infected, and 
in quin^ the abscess lies beneath the tonsil cauring it to extrude and push- 
ing it across the throat. 

The s^ymptom in all cases indude redness and inflammation of the tonsils, 
with a yellow exudate oozing on to the surface; the condition is accom- 
panied by a rise in temperature, rapid pulse rate and marked malaise, 
thd tongue is uiuaUy dirty and the breath offensive, swalkiwing is 



7a8 , THB BA&, NOSE AND THROAT 

difficult and paitdul and the local lymphatic glands become swdleit and 
tender. ■ ■ 

Treatment. Good success haa attended the use of the sulphanllamide 
compounds (see p. 338). Rest in bed, a liberal fluid diet, a daily bbwd 
action smd a four-hourly record of tanperatTorc and pulse arc important. 

Local treatment employed may be frequent swabbing of the infected 
tonsils to remove die exudate — or gargling, when the patient can manage 
this — ^but when the throat is very inflamed gargles become useless, as the 
fluid does not pass far enough into the throat to have any effect. Sjningmg 
the throat is often found to be very comfortable, and it should be carried 
out with the patient lying on his side, his head over the edge of the bed 
and a receiver held beneath it; fluid is passed into the lower cheek, using 
a rubber catheter and Higginson’s syringe. If quite gende singing is 
employed it is found to be very comforting and gives much reuef. 

The treatment of quinsy is similar, though in some cases the physician 
decides to open the abscess, feeling for the most tender spot and inserting 
a knife for about half an inch to drain the pus out. It is important for 
nurses to remember that tonsillitis may be associated with rheumatism; 
in most cases the organism of tonsillids is a very virulent one, producing a 
very grave condition of toxaemia and necessitating a long convalescence, 
a change of air and the administration of good nourishing diet in order 
to increase the resistance and raise the general health of the patient. 

Tonsillectomy. In patients who have complained of frequent sore 
throats and whose tonsib are enlarged and unhealthy, the operation of 
tonsillectomy is frequendy undertaken. 

In the preparation it is necessary to attend to the hygiene of the mouth 
for some days beforehand, the usual general preparation being also 
employed. 

The post-operative care. Bleeding is the complication to be feared and this 
danger must be in the mind of the nurse from the moment she receives 
the patient back into bed until he is out of her care. The position in which 
the patient should lie until he comes round from the anaesthetic is on his 
side, the shoulders should be higher than the head, and the face should be 
seen and be in such a position that any blood will run out of the nose and 
mouth and not down the throat. The mattress is tilted up behind the 
patient to prevent his turning over and lying flat. The bed is protected 
by a drawsheet folded in four and an anaesthetic cloth is under the patient’s 
face — a kidney dish or receiver might be placed under the nose and mouth 
to receive fluid or blood as it runs out. It is important that the mouth 
should be kept open and this position maintained until the cough reflex 
is thoroughly well established. Whenever in charge of cases after tonsillec- 
tomy, nurses should see that the patient is not swallowing blood, for the 
act of swallowing in such a patient usually means that bleeding is quietly 
going on unobserved. (See figs. 250 and 251, p. 709.) 

The throat will be very sore for some daya after the operation and it is 
usual to employ aspirin gmrgles — 5-10 grains in an ounce of watra: — ^before 
asking the patient to sw^low fluid or food. As a rule it is employed three 
times a day and the nurse must find out whether the surgeon wishes the 
patient to swallow the aspirin or not. 

The mouth and throat must be kept very clean and for this purpose 
antiseptic gargles of glycothymcflin are employed three times a day after 



AFFECTIONS OF THE THROAT 739 

tltti tiuree iniun Hieab. notH^ing drinks given in between meals 
slRiuM^ be followed by a drink of water in order to cleanse the throat. 
Hie diet is visually fluid until the soreness disappears; milk riiould not 
be employed as this tends to form a layer over &e throat; children will 
be foiu^ to be able to take jelly and ice-cream with comparative ease and 
pleasure. 

As a rule children are kept in bed for 2 or 3 days and return to school 
after 10 days. In adults the shock of the operation is greater and they are 
kept in bed 5 or 6 days and ought to have a holiday and not return to 
work for a month. 

ComplicaHom. The complication most to be feared is bleeding. If this 
happens the nurse should notify the doctor; he may order morphia, but 
he should see the patient again 15 minutes afterwards and, if the bleeding 
is not being arrested, he may wish to apply a tonsil clamp. The nurse 
should prepare the articles in fig. 252, p. 710. A tonsil clamp is never used 
by a nurse, but she should provide a small piece of gauze as shown in the 
illustration and larger pieces to guard the skin of the neck from injury 
by pressure of the external 'blade. Once the tonsil clamp has been applied 
the doctor will decide how long it should be left on; he may say i or 2 
hours, for example, and he may leave it for the nurse to remove. 

To remove a tonsil clamp it should be gently loosened, one ratchet at 
a time, until it ceases to exert pressure, and it may then be lifted off. If 
bleeding occurs again the doctor must be informed. 

Other dangers occasionally met with are sepsis, earache and secondary 
haemorrhage. In many cases where complaint of earache is made after 
tonsillectomy, relief may be obtained by putting glycerine and carbolic 
drops into the ear, covering it with a pad of warm wool and bandaging it 
on. It is important to see that the patient is not spitting blood before he is 
allowed to get up, as this would indicate the onset of secondary haemor- 
rhage. A rise of temperature usually indicates the onset of sepsis. 

Advice to patients going home. After any operation on the throat the patient 
should be told to avoid vigorous movement as this may make the nose 
bleed. If this should happen he must be told to sit quiedy in a chair and 
put a handkerchief soaked in cold water each side of his neck. If this does 
not stop the bleeding he should send for his doctor. 

INTUBATION 

Intubation of the larynx is performed by inserting a metal or vulcanite 
tube into it, the instruments used being O ’Dwyer’s intubation set, which 
consists of a set of tubes of various sizes, an intubator for introducing the 
tube, and a mouth gag; an extubator for removing the tube is also sup- 
plied although this is rarely used. 

An intubation tube is hollow, and has a small lip at the upper end 
pierced in one place by a tiny hole through which a silk thread is passed. 
Hiis is fastened to the outside of the che^. 

Intubation is valuable in obstruction of the larynx when it is not desir- 
able to make an incision, and it is performed for many cases in which 
tracheotomy would formerly have been used. 

In the nursing care of these cases the nurse should see the tube is not 
coughed out. She riiould have ready at hand a second tube, mouth gag 
and intubator, and also the instruments necessary for perfonning trache- 



730 rms ear, nose and throat 

otomy (sec fig. 353, p. 71 i). Zfthe tube becomes Modied the auise=s^ 
send for die doctor and remove the tube, eidier by pulling it out by the silk 
thread, or by exerting pressure on the tube. To do this a filler and thumb 
should be placed on eadi side of die trachea above die level of the thyroid 
cardlage; th«a, with the back of the head supported by the left hand, the 
tube is easily jerked out of the larynx by pressure of the right hand. Instane 
hoi^tals nurses are taught to reinsert a tube, but this is not invariable. 

The padent is usually nursed flat and may be fed widi the nasal tube or 
by means of a spoon; in the latter case the head should be held well back 
and food of soft solid consistence passed to the back of the mouth on the 
spoon. In the case of children it is necessary to prevent the child fiom 
attempting to pull the tube out, and inmost cases it will be found advis- 
able to fix cardboard splints to the flexures of the elbows. 

TRACHEOTOMY 

This operation is in England more commonly performed than intuba- 
tion, in the relief of laryngeal obstruction. The instruments required arc, 
tracheotomy tube and pilot — the tube should be ready taped — scalpel, 
tracheal dilators, two double blunt hooks to act as retractors, and one 
sharp hook to steady the trachea, probe, sinus forceps, artery forceps, and 
dissecting forceps; scissors and a blunt dissector should also be supptlied 
(sec fig. 253, p. 7 n ) . Sterilized towels, swabs and gauze will be need^ and 
a tracheotomy pillow or sandbag and mackintoshes. See also figs. 255-6, 
P- 713- 

The nurse should be prepared to assist the surgeon during the perform- 
ance of tracheotomy as an emergency measure; there may not be time for 
the patient to have an anaesthetic; if a child, he should be rolled in a draw- 
sheet and blanket, reaching from the nipple line to the iliac crest, the 
arms being pinioned to the sides of the body beneath the drawsheet which 
is securely pinned; the child is placed on his back on the table and a 
tracheotomy pillow or sandbag should be placed under the upper part of 
his shoulders — not imder his head — ^the head should be tilted well back, 
and the occiput tucked well under, in order to bring the trachea or front 
of the neck prominently forward. 

During the performance of the operation it is essential to keep the head 
and neck in a straight line, so that the trachea does not deviate to either 
side. One nurse standing at the head holds it, on either side, keeping it in 
position; a second nurse standing against the side of the table leans across 
the child’s body, taking hold of the arms above the elbows in order to 
steady trunk and pelvis. It is important to prevent rotation of the pelvis. 

The post -operative nursing care. The patient should be received 
back to a warm bed or cot, which should be elevated at the foot, in order 
to relieve shock and also to assist the gravitation of mucus from the res- 
piratory tract to the opening of the tube. The air of the room should be 
warm, about 65° F., and in some cases it may be desirable to moisten it 
by the use of steam. A patient who has suffered from laryngeal obstruction 
may be very fatigued and tend to sleep; it is important that this sleep 
should not be disturbed. 

In her nursing care of patients tmon whom tracheotomy has been per- 
formed the most important point for the nurse to attend to is the main- 
tenance of an adequate amvay. The inner tube is removable, but it may 



TSJtCUaKOTOMV 73I 

become Hocked, and wbenever thia happens the nurse should remove it, 
deahse it ’vyidi warm sodium bicarbonate solution, shake it free of moisture 
and remsert it; In a wdi-fitting tracheotomy tube the inner tube is easily 
rejotovable; at the same time care should be taken not to hurt the patient, 
and in performing this office the outer tube should be steadied while the 
inner tube is removed. For bedside tray see fig. 254, p. 712. 

If removing the inner tube does not relieve the obstruction the nurse 
should send the doctor and watch the child carefully in the meantime, 
and if his distress is very severe she must cut the tapes, remove the outer 
tube, insert the tracheal dilators and keep the trachea gently open imtil 
the doctor arrives. In using dilators the nurse should not open them too 
far-T-if she docs so, she will tear the trachea; the blades should be gently 
held apart. 

The length of time the tracheotomy tube is kept in depends entirely on 
die cause of its insertion. In a few cases there is difficulty in getting the 
patient to talk after removal of the tube — he seems afraid of his own voice 
— and another point of difficulty is that the patient fails to open his mouth 
when he couglu, as hitherto he has been coughing through the tracheo- 
tomy tube. To obviate the former difficulty it is advisable to get the patient 
used to the sound of his own voice before the tube is taken out by teaching 
him that if he places his finger over the opening of the tube he can speak. 
After the tube is out he must be trained to open his mouth when he coughs. 

If the tracheotomy tube is to be kept in permanently the metal tube 
will be replaced by a rubber one after the first few days and the patient 
will be taught to take this out, clean and reinsert it. 

'The complication most to be feared in the post-operative nursing care of 
tracheotomy is pneumonia, and it should be remembered that the patient 
is breathing the air of the room directly into his trachea; it is for this 
reason that the temperature of the room should be high, and the air 
moistened and filtered by means of a piece of gauze placed in front of the 
opening of the tube. In a few instances a little local suppuration may occur, 
but this is usually preventable, and sometimes there may be some local 
emphysema; when this happens the tissues of the neck will be seen to 
swell, and when the hand is placed on them a crackling sensation will be 
heard and felt; it is not usually severe enough to be serious, and the air will 
be absorbed after a few days. 

LARYNGECTOMY 

Either partial or complete removal of the larynx may be undertaken. 
It is usually performed when a growth is present in the upper part of the 
respiratory tract. In some cases preliminary tracheotomy will be per- 
formed, while in other cases the trachea is turned forwards and sewn to 
the skin and a tube is worn pennanently. 

The post -operative nuralng care of these cases requires great 
patience, tact and observation. The procedure is a great strain on the 
patient’s mental stability, as for some days he will be unable to speak and 
will find feeding very difficult. These patients are usually elderly people, 
and the disturbance of their routine mode of life becomes very distressing 
to than. 

The patient should be nursed sitting upright, his chest should be care- 
fully protected by a warm jacket and the skin on the front of his chest kept 



732 THE EAR, MOSS AiHD THROAT 

as dry as jxmible, as there is a good deal of leakage of mobture finm the 
wound, making the skin wet and cold. It is impHaitant to keqp die head 
v(^ sdll, as movement dela^ healing. The patient should Iw provided 
with a and pencil on vdmh to write his wishes, and a bell should be 
within reach at all times. He must be made to feel that there is someone 
\dthin call, and that the moment he touches the bell he will be attended to. 

The treatment of post-operative shock will bp carried out as necessary, 
rest being very important and If the patient is elderly it is advissdtle to give 
a fair amount of stimulant. Feeding will be a difficulty; in some cases the 
patient may be able to swallow fluid or soft solid, in other cases he will be 
fed by means of a tube passed through an opening in the iMck into the 
oesophagus, which will kept in position until the parts are healed. In 
many cases, when a patient begins to take food by mouth, there is a ten- 
dency for it to regurgitate through the wound on to the skin of the neck; 
the nurse standing by should cleauise it as it occurs, and gradually, as heal- 
ing takes place, this difficulty will disappear. 

The prognosis of such cases is always grave, and every posable means 
mvist be taken to obtain rest and sleep for the patient and to maintain a 
good resistance and tone of the body by the administration of as liberal 
and nourishing a diet as it is possible to give. 


HARELIP AND CLEFT PALATE 

In the development of the face fusion of the necessary parts may be in- 
complete. The commonest deformities, due to arrest of development here, 
are harelip and cleft palate. The deformity may be combined; when this 
occurs the nose and mouth are one cavity and there is difficulty in feeding 
the infant with the inevitable result of wasting. Owing to the communica- 
tion between the two cavities, nose and mouth, the mucous membrane of 
the nose soon becomes infected, which gives rise to chronic catarrh with a 
tendency to bronchitis and broncho-pneumonia. Infection of the middle 
ear may also be caused. Some babies with harelip and cleft palate are 
undersized and debilitated at birth; but even in cases of normal weight 
the difficulty of feeding readily gives rise to digestive disturbances early 
in life. 

Harelip. The cleft is usually in the upper lip ; it occurs to the side of the 
lip and may occur on one side, unilateral, or both sides, bilateral harelip. 
The condition may be complete when it extends into the nostril, or it may 
be incomplete, not involving the nostril. 

The treatment is operative and it is usual to operate on hauelip at the age 
of 2-3 months, repair of cleft palate is performed later. Before operating 
on harelip it is necessary to train the infant to take fbod from a special 
spoon (see fig. 267, p. 733). Operation consists in repair of the edges of the 
division in the lip and in bringing the parts together with as little tension 
as possible. Fine ophtlialmic silkworm gut is for the skin. A general 
anaesthetic is given. 

After operation two dangers have to be considered. ( i ) Tension which may 
be due to dragging together the sides of a wide gap, or to movmient cn 
the face muscles in crying. The use of Logan’s bow as a ‘tension bridge’ 
is recommended (see fig. 265, p. 720 and fig. 267, p. 733). This is worn for 
2to3'weeks. 



HARELIP AND CLEFT PALATE 733 

^a) Sepsis. Nasal discharge must not be allowed to flow over the wound, 
as It is irritating and delays healing. This can be prevented by keeping a 
little loosely rolled cotton wool in the nostrils which will absorb the discharge, 




Fig. 267. — SPEcaAL Deep Spoon for peeding Cleft Palate and Harelip Babi{5S. 

Logan’s bow (Sec also Fig. 265, p. 720). 

this cotton wool must be changed immediately it is soaked and when discharge is 
profuse it will need changing frequently, but it is important, and is part of 
the intelligent nursing co-operation upon which a surgeon is so dependent. 

The stitches may be swabbed with saline and weak peroxide and 
smeared with flavine i/i,ooo in paraflSn which is both protective and anti- 
septic. Stitches are removed on the sixth or seventh day and the infant is 
sent home wearing Logan’s bow. 

Feeding. It would be ideal to have these babies fed with expressed breast 
milk for the first few days and put to the breast as soon as possible, but in 
the majority of cases, owing to the deformity, breast feeding has proved 
difficult fi"om the outset and most of the babies presented for treatment are 
being artificially fed. 

The spoon shown in fig. 267 is an ordinary teaspoon compressed to 
trowel shape. It can be used in feeding both harelip and cleft palate cases. 
After each feeding it is important to give water so that the mouth is kept 
quite clean and no milk remains in it. To prevent the baby rubbing his 
face light cardboard splints may be bandaged on to the front of his elbows 
so that he cannot bend them. 

Cleft palate. The palate forms the floor of the nose and the roof of the 
mouth. When it fails to unite the cleft may be partial or complete. A bifid 
uvula is fairly conunon; the cleft may involve the soft palate as well as the uvula 
or it may extend farther and involve part or the whole of the hard palate. It may 
be associated with harelip or occur independently of this. 

The treatment is to repair the cleft by trimming the edges and bringing 
them together without tension. This operation is usually performed when 
the child is from i J to 3 years of age; by this time the mouth is large enough 
to permit of a reasonable amount of manipulation and the child old 
enough to be persuaded to be good and not cry. 

During the years of infancy a child with cleft palate requires to be care- 
fully fed as the cleft in the palate mzikes mouth and nose one cavity. For 
this purpose a special teat, Carmichael’s teat, which has a flap that fills 
up the cleft in the roof of the mouth, may be used, or a teat with a large 
hole so that the feed runs easily, or the baby may be spoon fed. Breast mUk 
may be expressed and used for feeding. Water must be given after each 
feeding. The nasal mucous membrane easily becomes infected, and in- 
fected adenoids and tonsils arc comparatively common. It is inadvisable 
to operate if infection is present and this requires adequate treatment first. 

Many surgeons remove the tonsils and adenoids before attempting re- 
pair of the cleft palate. Another consideration before operation on cleft 




734 THROAT 

palate can be undertaken is that the tiny child ^ould be nursed in the 
surroundings and amongst those who will look after him after operation, 
long enough to get quite used to them, and be able to be happy and con-^ 
tented in their care. He should be trained to take fluid from the special 
spoon. In many cases infants admitted to hospital for cleft palate operation 
are not well nourished and should be given a liberal diet erf soft nourishing 
foods so that weight and general condition may be improved. In some 
cases sedatives such as small doses of chloral or nepenthe will be given 
before operation in order to have the child in a quiet, sleepy state for a 
few days after operation. 

Post-operative care. At first the child may have difficulty with his intake 
of air owing to closure of a large cleft between nose and mouth; he should 
be watched carefully and given a little oxygen if necessary; quite soon he 
will learn how to breathe. He should be propped up on several pillows or 
held upright in the arms. 

As it is essential that his mouth be kept closed he must not be allowed 
to cry. He should sleep as much as possible, and when awake he must be 
kept amused but not made to laugh. 

Some physicians continue the use of nepenthe or chloral or some other 
sedative for a few days ; some ako give a little atropine to inhibit secretion 
in the upper respiratory tract; this makes the child thirsty, but so long as 
he is content to sip fluid from a spoon he may have as much as he wishes. 
The fluids given at first ought to be water, lemonade with glucose and 
whey, avoiding milk and all tacky fluid. The object is to keep the mouth 
as clean as possible. There should not be any need to clean the mouth; it 
should never be opened for this purpose, but the child may be given sips 
of water frequently. The child must not touch his mouth with his hani^ 
and he may need to have his elbows splinted in order to restrain him. 

A general anaesthetic is asually given when the stitches are removed. 

Cases unsuitable for operation may have palliative measures by the in- 
sertion of an artificial plate to fill the opening. 

The instruments required for some of the operations mentioned will* be seen on 

pp.yoyS, 7 //, 7x3-19, 



Chapter 45 

Affections of the Eye and their Nursing Care 

Ex<imimtion qf the eye—AJ^eetion$ of the lids: siies^ cysts^ blepharitis^ lachrymal 
ohstiructitm — Cofytmctivi^: pink eye^ purulent and gonorrheal conjunctivitis— Affec- 
tions of the cornea nnd irif: comeal ulcer ^ keratitis, arcus senilis, iritis — Affections 
of the tens: cataract, preparation and post-operative nursing — Glaucoma — Detached 
retina — Enucleation of eye. 

THE NURSING OF CASES OF DISEASE OF THE EYE 

T he care of eye cases requires a nurse who is very much alive to her 
responsibilities and exceedingly interested in her patients. It needs 
very special people who should have had equally special training, 
and yet in the ward allocated to diseases of the eyes in a general hospital 
many changes will invariably be made in the junior nursing staff during 
any one period of 12 months; it is specially important therefore that both 
the ward sister and the staff nurses should be highly experienced. 

One of the points that will strike the newcomer to such a ward may be 
the rigid adherence to conservative treatment in the preparation and post- 
operative care of patients, and the apparently exaggerated fussiness in 
attention to detail practised by surgeon and ward sister; but it will soon 
be realized how very necessary this all is and how often the success of the 
nursing of eye cases depends on the very minutest attention to small detail, 
as well as on the most exquisite accuracy in carrying out Instructions, and 
on careful observation. 

A nurse can be of little use in making observations in conditions and 
diseases of the eye unless she is familiar with the anatomy and physiology 
of this organ and its appendages; she should therefore take every oppor- 
tunity of being present at the ward round of the surgeon and in the oper- 
ating theatre, watching every detail as closely as she can, and following 
each step of an operation with such intelligence as is only possible if she 
has a sound knowledge of the anatomy of the parts which are being 
handled. 

Imagination is valuable and so is common sense — for example, if an 
eye is to be operated on and there is nothing external to distinguish it, 
the affected side should be marked by blue pencil or a strip of adhesive 
strapping; if eyelashes are to be cut, common sense with imagination 
might help a nurse to foresee that, unless the precaution of smearing them 
with vasdine is taken, stray hairs will be likely to fall into the eye and 
irritate it. 

Relaxation is essential, but it is impossible to relax if one expects to be 
hurt; the precaution of telling a patient exactly what is going to happen 
and the behaviour expected of him should always be taken, and then his 
co-operation may be expected. If the fingers of the nurse handling an eye 
9ire stiff and rigid they vrill hurt; gentleness is specially necessary in the 
nursing of eye cases, and the hands of the nurse should also be comfortably 
warm, and she should take care to keep them soft luid free from roughness 
and chapping. 


735 



'^ 4 : ;Am^ONrOF'TH»,SyE.. ' 

&e Vi^ has a rubber floor they 

Acaiii many instances boflt 

m Jpali^ iw h^ te 80 #a.t be k bhndfolded; in approaching the 

bm of tids {Mlticttt the nurse should move quietly but not stealthily and 
should take die precaution of speaking gently before she touches the bed. 
When instructing a patient to move his eye he should be asked ‘gently to 
dose or open it’, as the case may be, rather than to close or open gently. 
It is imperative the word gently should be emphasized, and that it should 
precede the direction to act. If the patient finds that keeping his eye open 
IS difficult he must not use his hands for this, but the assistance of anouier 
nurse should be obtained. 

EXAMINATION OF THE EYE 

The articles provided for examination of the eye are shown in fig. aflS, 
p. 737. The surgeon first inspects the eye in a general manner and notes 
the position and movements of the lids, the condition of the conjunctiva, 
the clearness or opacity of the sclera, the colour of the iris and the size and 
regularity of the pupils. 

He likes the patient to be so placed that the light falb on the eye from 
above and firom the opposite side to that on which he b working. He may 
evert the eyelids and examine the condition of the eye, and he tests the 
condition of the normal reflexes and the tension of the eyeball. He may 
wish to investigate any injury to the cornea by using fluorescein. He places 
a small drop on the margin of the cornea and allov^ it to run over u. An 
abrasion or an ulcerated area which b deprived of epithelium will stain 
green, but healthy parts are unaffected by the fluid. 

When he wbhes to illuminate the eye he will use a magnifying lens to 
direct the light on to the eye and a comeal loupe or lens or an ophthalmo- 
scope in order to inspect the different parts of the eye. 

If the surgeon wbhes to have the pupil dilated before the examination 
b carried out he will order atropine or homatropine. The nurse should 
see that the pupib are adequately dilated before the time of examination. 
For a more extensive examination the surgeon may wbh to cocainize the 
eye with a solution of 2 per cent, or 4 per cent, cocaine and he may need 
an eye speculum. (Thb instrument can be seen in fig. 273, p. 741.) 

AFFECTIONS OF THE EYELIDS 

A sty (hordeolus) b infection of a lash follicle ; a small abscess forms and 
there may be considerable swelling of the surrounding tissues, because 
the skin covering the eyelid is loose and does not contain a layer of fat 
as docs subcutaneous tissue ebewhere, consequently fluid collects rapidly 
in thb region. 

The local treatmeni b to apply hot mobt dressings (see p. 746) ; the in- 
fected eyelash should be removed as soon as it becomes a little loose; the 
application of weak mercurial ointment to the margin of the affected lid 
will act as an antiseptic and, being greasy in character, will prevent the 
lids firom being fastened together by the sticky exudate or discharge 'Mffiicfa 
is usually present. 

It is necessary to investigate the cause of repeated sties; the condition 
may be due to some genei^ constitutional disease or to debility; on the 



737 


Evr Ex A M IX s~ ION 

f 

isT'f' " ; j 



Fk;. 2G8 . — see page 736, 

The articles required for an examination of the eye include — (A) light, 
(B) ophthalmoscope, (C^) binocular lens or loup, (D) single lens, 
(E) corneal lens or loup. 







Fic,. •2b9 . — see page 746. Tht* articles rrcjuirccl for irrigating the eye 
by using an undine*. 



Kic;. '270. .see page 74^. The artulc-s recjuired fur hoi bathing the 
eye. The woexien spcjon i.s paddeci on the curved side. A pad of warm 
wool is bandaged over the eye to prevent chilling aft<*r hot bathing. 




riu. Uf'i. 

An eye operation drum con- 
tains a variety of minute 


740 



y CTJ - 


C3 *13 






no u 

S XJ 

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o Oi a 

to ^ 

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5 o c 

to CAJ 


s-s-S 


1, "" 

«j D bfj 




^00 
Cu ^ 
^ u- 

^ o o 


"C ! 
r:' -1 

-2 a. 

= "5 


o 

’m 

cC 


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to 

o o 

<u 
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a 


a ^ 

^ c/, C3 

C^rt.2 


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rt TJ u Cl. 


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i> ^ u 
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8.2 g 


(D 

W) 

r 3 • 

-o t: 

s .a 

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.~4 IL> 

.5 

ai 

Si CTJ 



741 



I k;. 274. Mr pa^e 749. or Lici.ssion. 

Rradin^ from Irft to rifcjhl: Spr('ulunK fixntinii I'orrrps. Saunde rs's 
rapsulr orcclk's. pipettr and cjlass rod. 







^ /i 4 ' 


I'k;. 273. See pa^e 749. iRiOhcnoMY. 

Reading from left to right: — Speculum, fixation forceps, keratome, 
Graefe’s knife, iris forcep>s, de Weeker’s iris scissors, iris repositors 
f'3 sizes), pipette and glass rod. 


743 



Fi(j. sec fnior 7 ', 2 . 'I rkphining ior Cii.Ai c oma. 

A liny circular culling instrument, a trcphiiK , is used to make a 
small opening at the limbus in order to allow fluid to escape for the 
redief of glaucoma. 

rhe articles inquired for trephining f(»r glaucoma are - 
(i) lh*PER Rem’. Speculum, three pairs fixation forceps (one pair 
plain), conjunctival scissors, splitting knife, trephine and iris forceps. 
(2^ Lower Row. dc Weeker's iris sekssors, thre^e iris repositors, disk 
forceyxs, needle in needle-holder and spool of silk, glass rexi and 
pipellc. 

(In addition the* artic les ic*quired lor irrigation of the eye should be 
provided, i 



744 



Fig. 277 . — see page 753. Enucleation of Eye. 
(i) Eyelid retractor, (2) fixation forceps, (3) Con- 
junctival scissors, (4) Beer's knife, (5) Strabismus 
hook, (6) Spencer-Wells's forceps, (7) curved 
muscle scissors, (8) needle holder. 

In addition, black eye silk No. o or i and curvtxl 
eye needles Nos. 3 and 4 will be recjuired. Peroxide 
may be needed to swab the eye cavity and a 
pressure dressing as shown in Fig. 272. 



Fk;. 278. Kid Drum used for 
testing the edgf*s of all cutting 
instruments used in surgi^ry of 
the eye. 



AFFECTIONS OF THE EYELIDS 745 

Other hand the sties may be secondary to some nncorrected error of refrac- 
tion, such as astigmatism. 

Cysts of the eyelids or meibomian (ysts are caused by abnormal develop- 
ment df the sebaceous glands secreting the fatty substance which is needed 
in order to keep the edges of the margins of the eyelids slightly greasy and 
so prevent the watery fluid from running out of the eyes. A meibomian 
cyst can be felt as a small swelling when the eyelid is taken and held be- 
tween the finger and thumb of the examining hand. The eyelid is uncom- 
fortable and painful, and the treatment is to incise the cyst in order to 
evacuate it and then to bathe the eye. 

Blepharitis is inflammation of the margins of the eyelids ; the eyes are 
red and sore, the margins ulcerated, the lids are inflamed and the lashes fall 
out, a sticky exudate forms and the red inflamed lids become glued together. 

The local treatment consists in removing the crusts from the margins of 
the lids by bathing with an alkaline solution such as sodium bicarbonate, 
two tcaspoonfuls to the pint of warm water; epilation of any remaining 
eyelashes is usually performed and the margins of the lids are smeared with 
weak mercurial ointment particularly at night in order to prevent their 
sticking together. 

The general health should be attended to, as blepharitis may be associa- 
ted with ill health. The eyes should be tested for errors of refraction for the 
same reasons as in the case of persistent sties. 

Ectropion is eversion of the eyelid which may occur when ulcers arc 
numerous on the lids. 

Epiphora is a flowing over of the conjunctival fluid on to the cheek; it 
may occur when the lids are everted, and also in lachrymal obstruction 
(q.v.); it also occurs whenever lachrymation is excessive as may result 
from any irritation of the conjunctiva. 

Entropion is inversion of the lids; it most commonly occurs as the result 
of contraction following ulceration of the lids, and in such a case the eye- 
lashes lie against, and irritate, the front of the cyeb2dl. 

Ptosis is drooping of the eyelids, usually of the upper one. 

Lachrymal obstruction occurs as the result of narrowing of the tear 
ducts which is often brought about by slight catarrh of these extremely 
delicate structures; the congestion first obstructs the duct and is then fol- 
lowed by permanent thickening which maintains the obstruction. In per- 
sons with a tendency to this condition it is found to be made worse by 
exposure to cold winds and by any slight irritation. If the contents of an 
obstructed lachrymal sac become infected a lachrymal abscess occurs; this is 
seen as a small painful red swelling just below the inner canthus of the 
eye; if the swelling is pressed upon the contents can, unless the obstruction 
in the duct is complete, be pressed out of the sac along the ducts into the 
conjunctival sac; the eye can then be bathed to remove the pus so released. 

The treatment of lachrymal obstruction is no| very satisfactory because 
the canal is so tiny, but attempts arc made to dilate it by passing a fine 
instrument along the obstructed canal. In persistent cases Ae sac is incised 
and removed. 


CONJUNCTIVITIS 

It^ammaHon qf the conjunctiva^ or conjunctivitis^ may be acute or chronic; 
it may also be catarrhal, as when it is due to some irritation or associated 

MM 



746 AFFECTIONS OF THE EYE 

with a cold in the head; it may also be infective, in which case it is pro* 
duced by a definite micro-organism. 

Whatever the cause may be, the early symptoms of all fprms of con- 
junctivitis are much the same; the patient complains that his eye feels 
gritty, he will often insist that he has a speck of dust or an eyelasn in his 
eye, though this is not so; the eye feels hot, the conjunctiva looks red and 
injected and may later become congested. Other classical signs include 
extreme watering, swollen eyelids and photophobia. 

Pink eye is a form of conjunctivitis which is due to a specific organism — 
usually the Koch- Weeks bacillus — ^and this form is infective, being rapidly 
spread by using the same towels, sponges, &c., and it quickly becomes 
epidemic among schoolchildren. 

The ordinary signs of conjunctivitis are present with, in addition, a 
muco-purulent dis^arge, and for this reason it is sometimes described as 
muco-purulent conjunctivitis. 

The treatment of the forms of conjunctivitis described above consists of 
fi^quent irrigation by means of weak antiseptic lotions — it is essential for 
the antiseptic to be weak, as a strong solution would injure the conjunctiva. 

An imdine should be used for irrigating an eye; the lotion should be 
warm, neither hot nor cold, it should always be tested on the back of the 
hand of the nurse before she lues it, and the undine should be held quite 
close to the eye and not at a distance above it. The patient may be lying 
on his back or seated in a chair, a receiver should be held closely against 
the side of his face to catch the lotion as it runs out of the eye. The patient 
is told to look up and the lower conjunctival sac is irrigated, and then to 
look down whilst the upper one is similarly treated, and thus lotion is not 
poured directly on to the cornea which would be irritating and possibly 
painful. When the treatment is over the eyelids should be carefully dried 
with small pieces of white wool. See fig. 269, p. 738 and fig. 271, p. 739. 

If the eye is very painful it will need rest, and for this purpose should be 
covered with a pad and bandage, but in no circumstances should eye- 
shades be employed, as these fit closely around the eye and bottle up any 
discharge which may be present, thus providing an ideal medium for the 
growth of organisms. 

Hot applications are ordered when the eye is very congested and painful, 
and these may be dry or moist. Dry heat is applied by means of an electric 
pad, so that the heat can be regulated. Moist heat is commonly applied 
by frequent bathing; a convenient method in common use is carried out 
by wrapping a pad of sterile wool on to the convex side of a wooden spoon 
(see fig, 270, p. 738); the patient is seated at a table — if in bed a bed table 
is used — a basin of hot lotion is placed in front of him and he is taught to 
dip the padded spoon in this lotion, press some of the lotion out against 
the side of the bowl and then, carrying the steaming spoon to the vicinity 
of his eye, hold it against the closed eye as soon as he can bear the heat of 
it. This treatment is repeated for from lo to 15 minutes every 3 or 4 hours. 

Whenever an eye Iw been treated by an application of heat it should 
be protected from cold air for at least 20 minutes afterwards; if a patient 
wishes to move about immediately after the treatment he should have the 
eye covered by a warm pad and bandage. 

Purulent conjunctivitis. Any form of pus-producing organism may 
give rise to purulent conjunctivitis, a very serious form of which, because 



ooNjUNaTtviTis 747 

the causative organism attacks the cornea, is gonococcal conjunctivitis 
(see note below). 

In the treatment of purulent conjuncHviiis the measures already given are 
employed; there is a creamy purulent discharge from the eyes, the lids are 
markedly inflamed and swollen and there is a tendency for the pus to 
collect, under tension, within the eyelids. 

In carrying out treatment for cases such as these the one additional 
point which requires attention is that irrigation must be sufficiently fre- 
quent to keep the eyes quite free of discharge; in severe cases almost con- 
stant irrigation will have to be employed, and it is therefore necessary that 
the lotion used should be bland and entirely non-irritating in character, 
such as cither saline or boracic. 

Gonorrhoeal conjunctivitis. This is a very serious form because it 
affects the cornea and destruction of this organ will result in blindness. 
Ophthalmia neonatorum is the term used to describe gonorrhoeal conjuncti- 
vitis when it occurs in the newly bom, the baby being infected as he passes 
through an infected birth canal; several days later the signs of conjuncti- 
vitis appesir, but fortunately babies have a good resistance to this type of 
organism so that in them the disease is much less severe than when it 
attacks adults. 

Ophthalmia neonatorum is a notifiable condition and preventive treatment, 
whether necessary or not, is carried out at the birth of every child by 
putting one or two drops of a weak solution of silver nitrate solution, usu- 
ally I per cent, strength, into each eye. 

In the treatment and nursing of severe purulent ophthalmia, 

such as gonorrhoeal, the chief care must be to prevent the collection of 
discharge over the cornea, as the gonococcus destroys the cornea and 
blindness would result. Irrigation is ordered to be carried out every i or 
2 hours, and oftener if necessary. Should only one eye be affected the 
sound eye should be protected by means of a Buller’s eye shield. The 
affected eye should never be covered. 

As the pus in the eyes is under tension, and is very infectious, the nurse 
who is bathing or otherwise treating the eyes must take precautions to pro- 
tect her own eyes; she should wear goggles, an overall and rubber gloves. 
In order to prevent spread of infection all the utensils used by or for the 
patient should be kept separate; all swabs and used dressings should either 
<>e burnt or put into i /20 carbolic lotion at once, until they can be taken 
to the incinerator; all apparatus used for cleansing the eyes should be 
washed in carbolic lotion and boiled before they are used again. 

A mild antiseptic is applied to the eyes once or twice a day; in many 
cases two drops of silver nitrate i per cent, or protargol solution, from 2 to 
10 per cent., is instilled. The lids may be anointed with weak mercurial 
ointment once a day. 

M and B 693 has been of value in some cases. 

AFFECTIONS OF THE CORNEA AND IRIS 

Corneal ulcer may be due to local injury or inflammation, or it may 
be brought about by debility. The surface of the cornea is covered by 
epithelium, as is the skin; if a superficial abrasion occurs it will heal with- 
out leaving a scar; but, if the deeper layers of this structure are involved, 



748 AFFECTIONS OF THE EYE 

scarring will result. The scar will be opaque and consequently sight will 
be interfered with. 

In comeal ulcer the eyes look red and inflamed and the ulcer appears as 
a greyish patch; the size of the ulcer is determined by the instillating of 
sever^ drops of fluorescein which stains the affected area green but does 
not stain the healthy surface, so that the shape and size of the ulcer are 
clearly defined. 

In treating cases of comeal ulcer it is important to try and discover the cause 
and then to direct treatment to the relief of this; the general health must 
be attended to, as when debility persists the ulcers tend to spread and 
become very difficult to cure. 

The ulcer is stained at intervzils to note its progress; if it is deep and is 
found to be spreading it is cauterized with pure carbolic; this is carried 
out as follows : 

Application oj pure carbolic to a corneal ulcer. The patient is placed in a posi- 
tion in which he is comfortable and can keep quite still, a good light is 
provided, the eye is cocainized with drops of 2 or 4 per cent, cocaine, and 
one drop of fluorescein is then instilled to stain the ulcer. A blunt orange 
stick is dipped in pure carbolic and the ulcer is gently touched with this; 
a small piece of blotting paper is used as a mop on the eye at the margin 
of the ulcer to prevent the carbolic from touching the healthy part of it. 
Pure carbolic destroys the structure and will leave an opaque scar. It is 
very important for the eye of a case of comeal ulcer to be covered with a 
comfortable eye pad; the condition is very painful, even the slightest ray 
of light causing great pain and distress to the patient which is accompanied 
by profuse watering of the eye. The pupU is kept dilated by atropine, and 
irrigation and hot bathing may be employed. 

Keratitis is inflammation of the cornea, and it is characterized by a 
non-suppurative inflammation which results in considerable opacity and 
so interferes with sight. It is most commonly met with in congenital 
syphilis. 

Arcus senilis is a degeneration of the cornea which occurs in some 

E ersotrs in old age; the cornea is composed of three layers — an outer, 
nown as Bowman’s membrane; an inner layer, Dcscemet’s membrane; 
and an intermediate layer which is described as the substantia propria, 
and it is this latter which is affected in arcus senilis. 

Iritis or inflammation of tlie iris is frequently associated with inflam- 
mation of the ciliary body and is then known as irido-cyclitis. It is due to 
disturbance of the general health, is sometimes associated with rheumatism 
and may follow influenza and may also be due to local sepsis. 

The iris looks dull and inflamed, an exudate forms and this causes the 
iris to become adherent to the lens, unless prevented by proper treatment. 
The patient complains of pain, especially when light fails on Ae eye (photo- 
phobia). 

Treatment. The main point in the treatment is to keep the pupil con- 
stantly and completely dilated so that there is no opportunity for a^esions 
to form between iris and lens. Hot bathing is employed, and the method 
described on p. 746 in the treatment of conjunctivitis by steaming the 
eye with a pad on a wooden spoon is particularly valuable in iritis. The 
general health should be attended to and the cause of the condition in- 
vestigated and treated. 



AFFECTIONS OF THE LENS 


749 


affections of the lens 

Cataract is opacity of the crystalline lens of the eye, the cornea remain- 
ing clear; such opacity interferes with vision and if the affected lens is 
removed there is a clear space provided for the passage of light into the 
eye, but the element which normally focuses objects is absent and there- 
fore such a patient will be obliged to wear strong lenses (glasses) in front 
of the eyes to make up for the absence of the crystalline lens. 

Cataract may be congenital, it may be caused by iryuty, it is a complica- 
tion oj diabetes owing to defective iiutrition of the eye and, lastly and most 
commonly, it is the result of degenerative changes taking place in old age 
and is then described as senile cataract. The majority of the cases admitted 
for treatment will be old persons, a few will be very young children. 

The treatment Jor cataract in adults is excision of the lens. In young children 
tlie lens is soft and the operation of needling or discission is carried out, the 
capsule of the lens being punctured, divid^ or incised by a sharp needle, 
permitting the aqueous humour which fills the anterior chamber of the eye 
to penetrate the lens, and this fluid dissolves the lens substance and washes 
it out of the capsule. 

In middle-aged penons and old people the lens is hard so that the 
aqueous humour has no effect upon it and the more extensive operation 
has to be performed. 

Excision of lens for cataract is carried out under a local anaesthetic , 
a knife is inserted at the margin of the cornea and taken across the an- 
terior chamber of the eye and out at the other side, a slightly sawlike 
movement being adopted in cutting, and two-fifths of the cornea formed 
into a flap and the upper part lifted as one lifts the lid of a box; sufficient 
pressure is then made on the lower part of the eye beneath the lowest 
margin of the cornea and the lens is slipped out of its capsule as a pea is 
shelled from its pod; none of the vitreous humour is allowed to escape. 

The operation of iridectomy is sometimes pierformed at this point, in order 
to lessen the danger of prolapse of the iris later on. 

The raised flap of cornea is gently laid back in position but is not 
stitched, and the parts must be kept quite still during the days following 
this operation, so that healing can take place, and it is for this reason that 
the care described below in the post-operative nursing of cataract cases 
is carried out. Once a, nurse has carefully followed the steps of this opera- 
tion she must realize that any increase of intra-ocular pressure will tend 
to separate the margins of the injured cornea and that any sudden or 
great increase of pressure will cause the contents of the eye to prolapse 
through this wound. 

Pre-operative treatment. The patient should if possible be in hos- 
pital a few days before the operation in order that certain investigations 
and observations may be carried out: 

( 1 ) Swabs of both eyes are taken to determine the presence of any micro- 
organisms which might contraindicate the operation since they would re- 
sult in sepsis. A few staphylococci albi and diphtheroids are not considered 
serious, but staphylococci aurei would necessitate delay. 

(2) It is impiortant to investigate the condition of the patient’s heart and 
lungs; he is elderly, and may have a cough or suffer from asthma, and as 



750 AOTEOTIONS 09 THE EYE 

complete rest and freedom from movement is necessary after a cataract 
operation the undue movement produced by coughing might be serious. 

(3) The patient’s mental condition should also be noted; elderly people 
are inclined to imagine all kinds of queer things, they will not be able to 
sleep at nights and in diis case they are inclined to get fidgety and might 
want to remove their bandages after the operation. 

(4) The bowels should be properly regulated so that the bowel is empty, 
the colon free from gas and the abdomen comfortable before the operation. 

(5) It is usual to test the urine for the presence of albumin which might 
indicate some renal failure, and also for sugar and diacetic acid which 
would indicate that the patient was a diabetic subject. 

(6) On the day before the op>eration it is desirable to keep the patient in 
bed in order to accustom him to lying on his back and to keep him quite 
still; he should practise the use of the bedpan lying down, learn to drink 
out of a feeding cup and be taught to turn over on to his side, that is, the 
unaffected side, to which he will be gently rolled in order to have his back 
rubbed and the drawsheet changed after the operation. 

The patient will wear a double eye bandage after the operation and this 
should be carefully fitted the day before; he might be allowed to lie wear- 
ing this bandage for an hour or so in order to get used to the sounds of the 
ward when lying with his eyes covered. The double eye bandage having 
been carefully fitted will be sterilized along with the other necessary ar- 
ticles in the special eye-operation drum. Some surgeons supply a wire cage 
or shield to protect the operated eye, and when this is used it should be 
carefully fitted and the edges bound with cotton wool. 

Immediate preparation. A local anaesthetic is given to adult patients for 
this operation because the effects of retching and vomiting would cause 
much movement and serious harm to the eye. The precaution of marking 
the eye which is to be operated on may be taken. 

Some surgeons like the eyelashes cut, though others do not have this 
done. To cut the ^clashes, smear the scissors with vaseline so that the hairs 
will stick to the blades, the type of scissors used being similar to small 
curved embroidery scissors, and the convex edjge beil^ used against the 
eyelashes. If the eyelashes are very long it may be possible to steady them 
by grasping with the finger and thumb of one hand, otherwise the patient 
should be told exactly what is to be done and asked to keep very still and 
quiet. 

The eye to be operated on should be prepared by having the pupil 
dilated, atropine being used for this; and it will be cocainized by a 4 per 
cent, solution of cocaine. The surgeon will usually give quite definite orders 
as to how often he wishes cocaine to be instilled, the strength to be em- 
ployed and the number of drops to be used at a time. 

Post-operative nursing care. After the operation the patient is 
wheeled quietly back to bed, both eyes are bandaged, the idea of covering 
the sound eye being not so much to keep light out of it as because each 
movement would necessarily carry the affected eye with it, as movement 
of the eyes is bilateral. 

The patient is placed gently in bed with one soft pillow, but if at all 
‘chesty’ he may be propj^ up on several pillows, the main point being 
that the head should be kept quite still and not moved. He has not had 
a general anaestibetic and therdCbre he is instructed to keep quite still and 



AFFECTIONS OF THE LENS 75 1 

then* 6-6 hours afterwards, with two nurses attending him he a gently 
turned to the unaffected side and his back is washed and rubbed. The 
lumbar region is apt to tecome very stiff and the nurse should take the 
opportunity of rubbing it well to stimulate the circulation and relieve 
the stiffness. 

Diet. During the first 12 hours many surgeons prefer that their patients 
diould have an all-fluid diet, drinking this from the feeder they have 
learned to use before the operation. As soon as they like they may have a 
light diet, such as crustless bread and butter and any other soft food, 
pounded fish and minced meat, anything, in fact, that they can manage 
to cat without having to bite and masticate it, as these movements, in- 
volving the temporal muscle, may cause movement of the eye. As the 
patient has both eyes bandaged, he must be fed. 

Bowels. As the bowels have been carefully regulated before the opera- 
tion, the giving of an aperient is usually delayed until the third morning 
and the patient should be warned not to worry about having his bowels 
opened as a small enema will be given if the aperient docs not act. In 
having a bedpan the patient should not make any effort at all, he must 
be lifted on to it and taken off by two or three nurses, and if left at all he 
must be so placed that he is quite comfortable and can lie without dis- 
comfort, stress or strain. 

Sleep and rest. It is very difficult to lie in one position and very boring to 
have both eyes bandaged and be unable to see what is going on, time is 
apt to drag and it is very necessary that the patient should have a really 
good night’s sleep; in many instances the surgeon will order a sedative on 
the first night and repeat it on other nights if necessary. 

Dressing. The surgeon will usually prefer to do the first dressing himself. 
The bandage is gendy removed, the eye is bathed with warm boracic 
lotion. In swabbing the eye the movement should be performed by sweep- 
ing the lashes from underneath upwards in order efficiendy to remove dis- 
charge — this is better than the usual method of swabbing the eye from 
within outwards. At the time of the first dressing the surgeon will carefully 
inspect the eye for any prolapse of the iris which would be seen as a litde 
dark mass at the opening of the wound; atropine is instilled, either atropine 
ointment or atropine i per cent, solution. The good eye is kept covered for 
the first 4 or 5 days, because it takes at least three days for healing to 
begin at the edges of die wound. After this time a single eye bandage is 
used for the affected eye. If the case progresses sadsfactorily the affected 
eye will usually be uncovered after the seventh day, dark glasses being 
then worn during the day, but it is advisable to cover the eye with a pad 
and bandage at night. 

For fear the patient should touch his eye during sleep it is usual to hobble 
the hands by ^ng them to the bedsides; considerable freedom should be 
allowed, but the bandage used should not be long enough to permit the 
patient to reach his face. In the case of elderly persons this may be found 
irksome and, if it is irritating, it is better that the hands should not be tied. 

The patient usually gets up about the ninth or tenth day for a short 
tiTTip but should be warned not to stoop or bend down as the wound is 
usually feeble for the first few weeks. As a rule the patient go« home about 
the fourteenth day, taking with him atropine drops to be instilled at night 
and being advised to attend for examination a few weeks later for the 
provision of special glasses. 



752 ABTECTIONS OF THE EYE 

In some elderly persons where the capsule of die lens becomes thick and 
fibrous it may be opaque and interfere with vision. When this happens it- 
is usual to make a hole through the capsule large enough for the patient 
to see through. This operation is called ‘needling’, but it is not the same as 
the discisMon describe on p. 749. 

Complications. Post-operative mania is probably the complication mosdy 
to be feared in elderly persons, since if it does occur, and the patient b(> 
comes quite irrational, the whole effect of the operation is spoilt. 

Prolapsed iris. The provision of absolute rest which has been insisted upon 
in the foregoing notes is essential in order that there should be no increase 
of intra-ocular pressure causing prolapse of the iris through the wound. It 
is to prevent this that iridectomy is often performed in the course of opera- 
tions for cataract. 

Sepsis may complicate an eye operation. This will result in conjunctivitis, 
delay in healing of the wound and reforming of the anterior chamber. 

Iritis and bleeding may also occur, particularly in diabetic cases. 

GLAUCOMA 

Glaucoma is increase of tension in the eye, and it may be acute or 
chronic — the chronic type is most commonly met with, the hijstory obtained 
being of gradually failing eyesight. 

Acute glaucoma comes on suddenly, with acute pain and congestion, 
accompanied by marked malaise, vomiting and much distress. If the 
patient is able to give any account of himself at all he may remember that 
his sight has been failing and that he has been seeing haloes round the 
light at night. 

The increasing tension in glaucoma is due to the fact that the fluid 
contained in the anterior chamber does not drain away as it should. This 
fluid usually drains into the general circulation by passing into a tiny 
vein at the side of the eye. When this is imperfectly carried out the shallow 
anterior chamber cannot increase in size and therefore pressure is directed 
backwards on to the optic disk, resulting in atrophy of the optic nerve 
and consequent loss of sight. The longer this pressure is allowed to remain 
the greater will be the interference with sight, and eyesight once lost can- 
not be regained by any medical or surgical method. 

In the treatment of glattcoma the first thing that every nurse should realize 
is in the nature of a negative prop>osition — that atropine should never be 
employed. On the contrary the pupil must be kept contracted and for 
this purpose escrine is used. 

In acute glaucoma the patient is admitted with the eye very injected and 
extremely painful. After the initial instillation of eserine, which aims at 
relieving the tension, hot eye bathings should be carried out, and leeches 
or other forms of counterirritation may be applied, just inside the outer 
aspect of the orbit. The patient should be kept as quiet as possible, the 
bowels should be well opened, and the administration of magnesium 
sulphate will probably help to relieve the tension. Light diet should be 
given. 

When a very acute case is admitted, the surgeon will at once be in- 
formed and the operation of iridectomy will be carried out. 



GLAUCOMA 753 

The surgical operative treatment for chronic glaucoma is to make a tiny 
opening at the margin of the limbus— that is, where the cornea joins the 
sclerotic coat of the eye — the ^e is cocainized as described in the operation 
for cataract, a tiny incision is made on the surface of the eyeball in the 
conjunctiva under the upper lid, the flap is turned downwards to expose 
the limbus and trephining is performed at the margin, resulting in a tiny 
permanent perforation through which the fluid in the anterior chamber 
can drain away under the conjunctiva, and it is usually successful. 

DETACHED RETINA 

The retina, which is the innermost coat of the eye, rests on the choroid 
from which it receives nourishment, arid if contact does not take place its 
nutrition is therefore impaired. Detachment of the retina is a very serious 
condition, as the main organ of sight atrophies and the detachment 
rapidly spreads until the whole organ is affected and if untreated the 
patient will become blind. 

Treatment is operative. The eye is cocainized, the eyeball is then very 
carefully retracted, the conjunctiva removed to expose the sclerotic coat 
and heat is applied by means of a diathenny electrode; this results in 
adhesions between the sclera and the retina. Before the end of the operation 
the sclera is punctured by a diathermy needle and the fluid which has 
collected between the detached retina and the choroid coat is evacuated. 
In successful cases the retina then falls back into its original place and is 
retained there by the formation of permanent adhesions. 

The preparation of the patient for this operation is similar to that described 
for cataract. The post-operative nursing care is also similar, except that for 
detached retina the position in which the patient is to be nursed depends 
on the site of the scleral punctures and will be specified by the surgeon, 
and both eyes are bandaged for 14 days. At the end of this time special 
opaque glasses with a small central opening (Loch-Brille) are worn on 
both eyes, and the patient is allowed to sit up and gradually to get up. 
Stooping, lifting and exertion are forbidden for several months. 

ENUCLEATION OF EYE 

Serious injury to the eye may necessitate enucleation of the eyeball. 

The instruments required for some of the operations mentioned will be seen on 
pp. 74^744‘ 



Chapter 46 

The Nursing Care of Cases of Surgery of the Brain 

Degrees of unconsciousness — The nursing of an unconscious patient — Preparation 
for an operation on the brain and the post-operative nursing care 

B efore considering or attempting to nurse cases of brain surgery, it is 
^ important that a sound knowledge of the degrees of unconsciousness, 
their significance and appropriate treatment, with special reference 
to the dangers which threaten the life of a patient who is unconscious, 
should be studied carefully. 

Degrees of unconsciousness. A person who is asleep is unconscious, but 
he will move and turn over if he is disturbed. A stuporous patient will not be 
affected by a slight touch, but he can be roused if roughly shaken and 
shouted at; a person who is in a deep state of stupor can be aroused by 
sustained pressure at the side of the bridge of the nose. A patient in coma 
cannot be roused. 

It is very necessary for a nurse to be able to recognize when uncon- 
sciousness is becoming deeper, and this has already been referred to in the 
note on cerebral compression on p. 600 and in the care of a case of 
fracture of base of the skull on p. 598. The main points to be observed 
are — increasing depth of breadiing; slowing and increase in volume of the 
pulse, fixation of the pupils together with absence of any reaction, dis- 
appearance of cough and swallowing reflexes. In nursing cases of injury or 
disease of the brain it is most important that accurate attention should 
be given to these points and that a written note should be made, with 
mention of the time, whenever any one of them is observed. 

The dangers of unconsciousness which a nurse should do her best 
to prevent are — fatal pneumonia from food, fluid, and saliva trickling 
down into the trachea; hypostatic pneumonia and bedsores resulting from 
the patient’s having been allowed to lie like a log. 

Nursing care. An unconscious patient depends entirely for his well- 
being, and possibly also for his life, upon intelligent nursing care. Ordinary 
routine nursing measures will be employed to prevent bedsores and to keep 
the patient clean, his mouth and eyes requiring particular attention. 
His urine should be measured and tested at regular intervals, his bladder 
observed for fear lest retention of urine should occur, and his bowels kept 
regularly acting and his abdomen watched for distension. 

Special nursing measures will be required in order to prevent occurrence 
of the complications mentioned above — inhalation and hypostatic 
pneumonia. 

Feeding. When a normal person eats or drinks and some of the food or 
fluid enters the larynx or, as it is called, ‘goes the wrong way’, the subject 
splutters and coughs and his friends give him a good thump on the back 
in order to dislodge the particle and so relieve his distress. Tins, in the case 
of an unconscious patient, unfortunately will not do, since the cough re- 
flex has been abolished anxi some of the fluid or food put into the mouth 

754 



BUROSRY OP THE BRAIN 755 

will therefore trickle slowly down into the trachea — to cause fatal pneu* 
monia later. ' 

Semiconscious patients who have a good swallowing reflex, and in whom 
the cough reflex is not abolished, may be fed in small amounts given from 
a spoon-r-a feeder should not be used. Many patients who are semi- 
conscious will chew if food is put into the mouth, and when the nurse 
discovers this she should, in preference to fluids, give such a patient semi- 
solid food such as jellies, thi^ ground rice puddings and porridge, which 
will cause him to move his jaws as in the act of chewing. 

A patient in whom the swallowing reflex is absent must never have food or 
fluid put into his mouth, but should be fed by means of the nasal tube. 
The use of an oesophageal tube for feeding purposes is not recommended, 
because passing this rather large tube results in regurgitation of fluid 
around the tube in the pharynx and mouth; this fluid will then trickle 
into the trachea unless the precaution is taken of letting the patient lie 
on an inclined plane with his head low. 

The fatal pneumonia already mentioned is not solely due to the in- 
judicious introduction of fluid or food into the trachea; another danger is 
the patient’s saliva. Various devices have been adopted to prevent saliva 
from trickling into the trachea, and one of the most efficient ways of 
accomplishing this is by the use of a suction apparatus — a catheter can be 
passed through the nose, with its end lying in the pharynx; negative 
pressure is then applied by means of a piece of tubing from the catheter 
connected to a tap, from which water is running. The patient is arranged 
on his side and the saliva which collects in his mouth and throat is sucked 
out by the negative pressure apparatus. 

If a nurse has to deal with an unconscious patient who is making a lot 
of saliva she should — spending the arrival of a doctor — arrange pillows 
under the trunk of the patient as he lies prone and support his head, with 
the forehead resting on a pillow or sandbag. A basin put on the bed be- 
neath the patient’s mouth will catch the saliva as it runs out. 

To prevent hypostatic pneumonia it is necessary to movte the patient fre- 
quently, at least every hour and a half, and then not gently; he should be 
thoroughly disturbed; if he is semiconscious and can be made to cough this 
is excellent, but even when unconscious the nurse may notice that his 
breathing is slightly increased in depth by movement. When deeply 
unconscioxis he ^ould be given inhalations of a mixture of oxygen 93 per 
cent, and carbon dioxide 7 per cent, at regular intervals. It is necessary to 
get good ventilation of the lungs if the danger of hypostatic pneumonia is 
to be obviated. 

The patient should be propped up in a different position each time he is 
moved; sometimes he may be drawn up the bed and propped, as if sitting; 
at other times he may be placed first on one side and then on the other. 

Prevention of deformity. Unconscious patients who are in bed for some time 
tend to get footdrop, and to help to prevent this it is advisable to use a low 
bedcradle over the feet to take the weight of the bedclothes — a footrest 
may also be used. The bedclothes should nevfer be drawn tightly over a 
patient’s feet when tucking them in. 

-Preparation of a patient for an operation for removal of a 
tumour of the brain. The routine general preparation of the patient is 
similar to that de«mbed on p. 630. 



75® SURGERY OF THE BRAIN 

A patient admitted to hospital for an operation on die brain may be 
in a good or a poor general condition. He may, for example, have been in 
a state of stupor for some days, and having taken little fluid and food during 
this time.it may be found that his mouth is dry, tongue dirty and teeth 
covered with sordes. His skin may be dry and he may be be^mning to 
develop bedsores. 

The surgeon will have to decide whether an operation is urgently 
needed or not. When possible it will be considered advisable to try and 
improve the patient’s general condition first. The symptoms mentioned 
above will be relieved and the general condition improved by the liberal 
administration of fluids by mouth, when the patient can swallow, or 
alternatively by rectum or by means of the nasal tube. 

It is very important for the surgeon to obtain ail the information 
possible before operating on the brain, so nurses will be called upon to 
make careful observations and be prepared to give a detailed report on 
anything they observe which might have a bearing on the condition 
of the patient. Observation which might help the surgeon to judge the 
position of a tumour of the brain or the extent of injury to the brain 
would include the following; 

Speech difficulties. A patient may be unable to express what he wishes to 
say. He may not understand what is said to him. 

Loss of memory. This may be complete or incomplete. Loss of memory 
may be remote or immediate and it may cover only a certain definite 
period of time. 

Hemiampia. In this condition the patient is unable to see as well on 
one side as on the other. He may not complain of this, but the nurse 
may notice that he only sees objects at one side of his bed. 

Stupor. If a patient is in a state of stupor it is important to notice whether 
there is any increase in the depth or the degree of unconsciousness, as 
this would denote increasing intracranial pressure. 

Changes in the character of the pulse and respirations. Any slowing of the 
pulse and increase in the depth of respiration arc symptoms which may 
•denote increasing pressure. 

Alteration in the size of the pupil or any inequality of the pupils. Either of 
these symptoms should immediately be reported, as the onset of these 
may be an indication that operation is urgently necessary. 

Fits and Convulsions. Any type of seizure the patient may have should 
be observed. With pad and pencil the nurse should write down the 
following particulars: the time the fit started, how it began, where 
jerking movements started and the order in which these progressed, 
how long the fit lasted, whether the patient lost consciousness during 
the fit and for how long he remained unconscious, how the fit terminated 
and the state of the patient after the fit, whether he wanted to sleep, 
complained of headache or whether he was restless and irritable. 

Any complaints the patient makes. No detail is too small to be of impor- 
tance and a nurse should note and report any complaint a patient may 
make. 

Before operation an X-ray examination of the skull is made and in many 
cases ventriculography (see p. 210) is performed in order to discover 
whether there is any displacement of the fluid in the ventricles of the tu'ain. 

During the operation a careful record of the pulse, respiration and blood 
pressure is kept. An intravenous drip infusion of saline or blood is set up 



SURGERY OP THE BRAIN 757 

80 that a blood transfusion can be pven without delay should this become 
necessary. Opeiations on the brain often take a long time — from 6 to 8 
hours — and the patient is not, as a rule, removed from the operating 
table until he has regained consciousness. 

Post-operative nursing care. On return to bed the head should be 
kept low at first. The bed is protected by a mackintosh and towel. The 
side which has been operated on should be kept uppermost. The pulse 
and respirations should be noted frequently, every half hour at first, and 
later every two hours. The temperature should be taken at two-hourly 
intervals. Should the temperature rise to 102° F. all bedclothing, except a 
covering sheet, should be removed; if it rise to 103° F the patient should 
be sponged with tepid or cold water. 

It is important to watch the patient carefully for any signs of increasing 
intracranial pressure such as slowing of the pulse, increase in the depth 0/ 
respiration, drowsiness increasing to stupor. These are probably due to pressure 
caused by blood clot which may occur during the first 24 hours after 
operation. It is essential to report any of these symptoms to the surgeon 
without delay and he will take immediate steps to remove the pressure 
because otherwise it may cause permanent injury to the brain. 

When the mouth is dry the lips, tongue, gums and teeth should be 
kept very clean and moist and it will be found that, as the patient can take 
fluids, his mouth will become clean, moist and comfortable. 

The position in which the patient lies should be changed every three hours; 
a patient who has had a cerebellar operation should not be placed on his 
back, but may be placed on cither side; a patient who has had an operation 
on one side of hb cerebrum can be placed on the opposite side, and on his 
back alternately. 

The patient may he given fluid, sucking it from a swab placed in his mouth 
for the first few hours after operation, until he has ceased to vomit. As 
soon as his swallowing and cough reflexes have returned he may be given 
fluids to drink; a spoon should be used until the nurse is quite certain that 
these reflexes are acting normally. He may then be given small drinks from 
a feeding cup. On the second or third day the patient can usually be 
allowed to sit up in bed and may be given a fairly full diet. 

The bowels are opened by means of an enema on the second day and 
magnesium sulphate is given regularly afterwards. It is the best aperient 
to use for cases of surgery of the brain, as it reduces intracranial pressure 
by removing fluid. Its use is commonly continued for months, not neces- 
sarily as an aperient but in order to effect the slight dehydration which 
is found to be necessary. 

If sedatives are necessary mild analgesics such as aspirin and pyramidon 
arc employed in preference to morphia which is likely to mask the symp- 
toms of increasing intracranial pressure should these arise. 

The dressing is usually performed on the second day, some of the stitches 
being taken out then, and It is repeated on the fourth day when the re- 
mainder of the stitches are removed. This is an advantage as, by taking 
the stitches out soon, stitch marks and wound scars are avoided — an im- 
portant point on an exposed area such as the scalp and forehead. 

The scalp should be kept clean, and this can be done by swabbing it 
with equal parts of methylated spirit and water; when the hair has grown 
brushing it will keep the scalp free from dandruff. 



756 SUROE&Y OP THE BRAIN 

Getting up. Cases of surgay of the brain are allowed to get up at the end 
of the first week, and they arc encouraged to mix freely wiA other patients. 
A certain degree of euphoria is present until the patient has completed his 
convalescence, and this is characterixed by an attmetive, obliging, very 
agreeable manner; with marked good temper which makes the patient a 
great favourite with others. 

The patient needs encouragement and re-education so that he may be 
helped to take his place in society again; when he has completely recovered 
his normal temperament may not be nearly as attractive as the one 
associated with the slight euphoria present after his operation. 

The instruments shown in fig. 234, p. 695, are some of those which are 
essential for decompression or trephining toe skull. Surgery of the brain is 
a very specialized branch and many surgeons have designed their own 
instruments. 



Chapter 47 

Orthopaedic Nursing 

Classijkatiofi of deformities — The treatment and care of cases met with in an 
orthopaedic unit^ including: Common congenital deformities — Flatfoot and other 
conditions of the feet — Deformities of the vertebral column — Deformities due to 
rickets^ to diseases of the central nervous system and to contractures 

T he word orthopaedics is derived from Greek and means ‘the 
straightening of children’. Orthopaedic surgery deals particularly 
with the parts of the body that are concerned with movement — 
the muscle, joints and bones of the trunk, back and limbs. 

It includes in its practice manipulations, operations on the structures 
mentioned, massage and remedial exercises. It is employed in the cor- 
rection of deformities, both congenital and acquired. The nurse who wishes 
to prepare herself for orthopaedic work should have a sound knowledge 
of the skeleton, the positions of the major groups of muscles and their 
action on joints, of the normal range of movement at joints and of its 
limitations. She should develop the habit of observation, and train herself 
to see errors of poise, balance and alignment. This can best be done by 
having an intimate kiiowledge of the normal poise of the body, in repose 
and during activity. She will then at once detect the irregularities which 
occur in abnormal conditions which if left untreated will result in deformity. 

It is essential that a nurse should learn to be constructive in the criticism 
she may make regarding errors of balance and poise. When for example 
a parent can be brought to see that his cliild is stooping a little, or habit- 
u^ly standing in an attitude which is likely to cause deformity, and then 
helped to realize that seeing a special surgeon now need not mean that 
surgical intervention is necessary, but that only a surgeon who has 
specialized in orthopaedic work is competent to suggest that some special 
exercises might be taught which would correct the condition before it 
becomes more serious. The nurse although she may recognize the con- 
dition, is not qualified to deal with it. 

CLASSIFICATION OF DEFORMITIES 

A classification of deformities^ not confined to those which affect only the organs 
of locomotion — with which orthopaedics is solely concerned— is given below, A 
deformity is a deviation from the normal physical structure. See pp. 

Gongenltal deformities arise before or at birth. The true cause is 
indiscoverable, but there arc many theories as to possible causes. Examples 
are, harelips cleft palate — ^thesc conditions are de^t with in ear, nose and 
throat surgery on p. 732. 

Spina bifida. This is a gap in the posterior part of the bony arch of the 
neural canal. Through this gap the contents of the spinal canal protrude. 
The complications are paradysis, infection and spinal meningitis. Treat- 
ment aims at closure of the opening when possible. 

Md'^scent of testes. The testes are arrested in descent to the scrotum; 
they do not develop and are liable to inflammation. 

759 



760 ORTHOPAEDIC NURBINO 

Failure df development of the intestinal canaL Occlusion of the oesophagus is rare, 
and is practically untrcatablc. An imperforate arms may be present, and it is 
possible to operate successfully on this. 

Congenital pyloric stenosis has been dealt with on p. 398. Congenital 
clubfoot and congenital dislocation of the hip, congenital absence of a bone in the 
upper or lower extremity, supernumerary digits in hands and feet^ webbed 
fingers or toes^ and congenital amputation of part of a limb may all be met with 
occasionally. 

Torticollis is frequently classed as a congenital deformity, but it is more 
probably produced by injury at birth than as the result of a develop- 
mental defect. 

Acquired deformities provide a twofold interest; the interest in- 
volved in discovering the cause of the deformity and the cure to be carried 
out combined with arrest of progress of the deformity. 

The causes of acquired deformities are numerous and include injury 
to the skeleton as in fractures and dislocation, and injury to the soft parts, 
burns for example, when the injury sustained may result in deformity 
due to the contraction of scar tissue. 

Disease of bones and joints. Arthritis, tuberculosis, osteomyelitis, tumours 
of bone, osteomalacia and rickets may all result in deformity of bone. 

Diseases of the central nervous system^ particularly infantile paralysis, may 
result in drformity. 

Disease and weakness of Deformity produced by muscle weakness 

may be only postural, as occurs in many cases of flatfoot, lordosis, scoliosis 
and kyphosis. It may also be the result of disease of muscle. 

Surgery may produce deformity. For example, amputation of a breast or of a 
limb, which may be necessary in order to remove a diseased organ, 
produces a definite deformity. The accidental division of a nerve in surgery 
will if the injury is irreparable, result in paralytic deformity. A ventral 
or incisional hernia, occurring in the region of an abdominal incision, is 
another example of deformity resulting from surgery. 

THE TREATMENT OF DEFORMITY IS DIVIDED INTO 
PREVENTIVE AND CORRECTIVE TREATMENT 

Prevention of deformities is necessary in the care of all surgical cases and 
especially in the case of burns and fractures. In the treatment of fractures^ 
the aim is to reduce the fracture and place the broken bones in correct align- 
ment \ and then to fix them in this position by means of splinting and ex- 
tension. Having performed this, and .arranged to have the necessary 
fixation maintained until the fracture has healed, the next very important 
consideration is to maintain the function of the limb or part affected. 

In the illustration attached for example the case is one of fracture of the 
femur; the limb is put up in a Thomas's knee splint, weights are planned 
to provide accurate balance in order to make it possible for the patient 
to use all his muscles all the time he is in bed. This patient was able to 
raise himself in bed on the first day, and to place himself on the bedpan; 
he could turn about from one side to the other in order to reach articles 
from his locker and bedside table at about the same time. Sec fig. 1 09, p. 2^7. 

In the care of cases of bums very close consideration must be given dunng 
the healing stage to prevent any deformity from contractures. The position 
in which the patient is nursed and the pliability of the superfiicial structures 



SOME CONGENITAL CONDITIONS AND DEFORMITIES 76 





Fk;. 279 {top), CONfiENlTAL DISLOCATION OF 

Left Hip. 

Flo. 280 . — see page 7G9. {bottom left ). Congeni- 
tal Clubfoot. 

Fkl 28 1 {bothm right ). Spina Bifida due to 
Congenital Malformation of the Spinal 
Column. 




SOME DEFORMITIES OF THE FOOT 



’ 773- Hallux Val(;i;s. 


I'kl see page 772. 

FLAlFOOr. 



I ’lc;. 2B8 . — see page ‘jikj. 
I alipes EquiNLs. 



Fig. 289 . — see page 77;^. Pes 
Cavis or Holi.ow Foot. 



Fio. 290 , — see page 773. Clawfoot. 



SOME DEFORMITIES OF THE "HAND 



Fig. 2H3. 





Fi(i. 282 also Fiji. 300;. 1 ) i , k>rmuy 
T>11E TO RmaiMAl'OID ARTHRins. 

Fig. 283. Ditpyfren's C^ontraciu^ns 

BEFORE AND AFTER TREATMENT. 

Fig. 284. I'lxTRA Digit (ConctEnh ai. 
Malform.mion of Thumb). 

F’"ig. 285. Uenar Deviation of Hand 

BEFORE AND AFTER TREATMENT. 


Fig. 285. 


DEFORMITIES OF THE SPINE 


7 % 




DEFORMITIES OF THE SPINE 76 r> 



Fig. 293. — see page 774. Scoliosis. 

Lateral curvature of the spine. Fig. 293 shows 
right dorsal and left lumbar curves. The curve is 
named after the convex side. The oppodtc or 
concave side of the curve shows depression of the 
structures of the trunk. 


R 


Fig. 294. — seepage 774. 
Scoliosis. 

Radiogram of spine 
showing the changes 
in position of the 
vertebrae which occur 
to produce deformity 
similar to that seen in 

Pig- 293- 




SOME DEFORMITIES OF HEAD AND TRUNK 



Fig. 295 . — see page Tortigollis. 



Fig. 296 . — see page 774. 
Round Back or Kyphosis. 



Fig. 2Q7. — seepage 774. 
Hollow Back or 
Lordosis. 




763 GOME DEFORMITIES DUE TO ARTHRITIS — chapter 49 







THE JWlfORMlTV 769 

must be constantly noted, in order to prevent either limitation of the 
nornud range of movement or actual detormity. 

The pmmtmn by era^catimt of dums and overcrowding, and 

by the provinon of welfare centres and adequate diet for all children, are 
factors of importance in the prevention of one erf the most ctippling of 
(fiiseaset. 

DEFORMITIES OF THE FEET 

Ckmgenital clubfoot is one of the commonest of these deformities; as a 
rule it is seen in the form of talipes equino^varus, but it may be present in 
other forms of talipes. The four main varieties of foot deformity are: 

Talipes equimts. The foot is plantar-flexed as in the position of standing 
on the toes. 

Talipes calcaneus is exactly the opposite deformity; the heel has dropped, 
as in ^e position of standing on the heel. 

Talipes varus. The tiont of the foot is turned inwards and the inner 
border elevated. 

Talipes valgus is exactly opposite to talipes varus; the front part of the 
foot is turned outwards, and the outer border elevated. 

Each of these deformities may occur alone, or two types may be as- 
sociated. As mentioned above, the coimnonest congenital deformity of the 
foot is clubfoot or talipes equino-varus, in which the foot is plantar-flexed 
and inverted 

The treatment of clubfoot should commence as early as possible; a 
few days after birth the foot may be manipulated into the correct position 
and maintained by adhesive strapping. The nurse in charge of the infant 
should see that this strapping does not get wet and she should also notice 
that it does not become tight. As a rule it is allowed to remain on for a 
week and is then renewed and the manipulation of the foot and application 
of strapping is repeated so that as the f^t grows it will improve in shape. 
In a slightiy older child plaster of ijaris may be employed, A specially 
adapted shoe, designed to maintain correction of the deformity, is necessary 
when the infknt begins to walk. 

When the infant is not seen by a surgeon until he is about 2 years of age 
the simple manipulation just mentioned is not likely to be sufficient to 
correct the deformity which exists. At this age it is usual to correct the 
deformity by manipulation of the foot under a general anaesthetic and to 
put on plaster of paris in which the child may walk about. If the condition 
u not treated until the child is 4 or 5 years of age, operation on the soft 
parts may be necessary, combined with manipulation and overcorrcction 
of the foot in plaster of paris. 

In older children the aeformity may be so marked that it is impossible 
for it to he corrected except by operation on the bones, and the removal 
of wedge-shaped pieces of bcaie is carried out in order to bring the foot 
into a normal position. 

The after care of cases of clubfoot has to be continued until the child has 
grown up, since the tendency for the foot to revert to the old position of 
deformity is ever present. Constant supervision of the function of the 
muscles controlling the foot, the mobility of the joints of the foot and the 
provision of suitable footwear is essential if any degree of success is to be 
attained. 


00 





110 


CONGENITAL BlSL<M3ATION OP HIP 

Cibngeidtal dislocation of the hip n»y be bilateral, or unilateral, when 
only one hip joint is affected. This condidon may not be noticed ipital the 
infant begins to walk, when it is observed that he develops an awkward 
gait widi marked lordosis and an ungainly limp. This is because the weight 
of the body pushes the head of the tonur up on to the external surface of 
the Uium since the head is not adapted, as it shouM be, to the acetabtdnm 
(see illustration, fig. 279, p. 761). 

Treatment. The aim of treatment is to obtain reduction of the dislo* 
cation without injury to the femoral head and it is now Oonsidered best 
to abduct fully the hips on an abduction frame (see fig. 302) and allow the 
dislocated feriiur or femora to descend gradually to die levd of the aceta- 
bulam. The child is put on a double abduction frame with strapping 
extension on both legs and the hips are gradually abducted as widely as 
possible. This may t^e a week to 10 days, the child is left on the frame for 
4 to 6 weeks and in that period of time the dislocation is usually reduced. 

The next step is to apply plaster of 

e aris after the method employed by 
fr. J. S. Batdielor. A general an- 
aesthetic is pven, the bandages and 
extensions are removed and die child 
is lifted from the frame. The affected 
femur is gently rotated, pressing it 
against the acetabular surface of the 
innominate bone, getting as much in- 
ternal rotation as possible and main- 
taining good abduction. Plaster of 
pads is &en applied. The limbs are 
^t wrapped in splint wool and then 
plaster of pads bandages are applied, 




Fio. 303,— Showcno Ckuu> wira OcmeararAi. Dihocatioh or rou.y aaoutniD 

ON fKAKS. 




Fio. 30^. — Showing Child in Plaster or Paris with Limbs internally rotated. 

the knees being fixed at right angles, and a bar adjusted between the legs 
as above. This position is maintained for 12 to i8 months, the plaster 
being renewed as often as necessary. The child gets used to the position 
in a week or two and may sit up and crawl around, but he should not be 
allowed to bang his hips about for fear of causing injury which might 
result in osteoarthritis, 

TORTICOLLIS 

Torticollis is usually the result of some injury during birth which causes 
ruptLue of certain muscle fibres of stemocleido-mastoid with the result 
that contraction of the injured side occurs. This type oftorticollis is painless ; 
the head is flexed to one side and the face rotated to the opposite side. 
The contracted muscle is scai to stand out prominently. 

The treatment is to divide the muscle either by subcutaneous tenotomy 
or by an open operation. The head should be kept in an overcorrected 
position until the divided structures have healed, to prevent their con- 
tracting again. This overcorrection may be maintained by sandbags at 
first, a^ afterwards by plaster of paris; or the head may be put in {^ter 
of paris at the time of operation. 

The plaster is worn for firom 4 to 6 weeks and then cut down and the 
child taught to control the movements of his head by exercises performed 
in firont of a mirror. The plaster splint may be worn in between the times 
devoted to exercise imtil the patient has sufficient control of the position 
of his head. 

Paralytic tortlcoUia is due to paralysis of the sternomastoid muscle 

one ride; As the result of this, the other, sound side, becomes shortened 
and eventutdly contracted because the action of the muscle is imopposed 
and therefore utfoalanced. The deformity of torticollis in this case, is on 
the ride opposite to that of the affected (paralysed) muscle. 

Spasmodic tortictrilis occms as the result of irritation the muscles 
of one side of the neck. It is somedmes associated with rheumatism, but 
it inay also arise in any painful omdition of die nedc. 



772 


ORTaOPABmO NURSIMO 


FLATFOOT AND OTHER CONDITIONS ASSOCIATED 

WITH IT 

Flatfoot may be congenital but it is much more often an acquired 
deformity and frequently postural in origin. 

The foot is made up of a series of bony arches; the inner loi^tudinal 
arch and the anterior transverse metatanal arch are those anttted in 
flatfoot (see illustration). The changes in the structures occur in the 
following order — The muscles which nomaUy susUm the arches of the foot m 
position may be stretched and weakened, and this may occur as the result of 



Fio. 305 — ^Thb Internal Lonoituoinal Arqh. 


illness, anaemia and debility, or owing to continued overstrain with 
fatigue, or as the result of slovenly habits in walking and standing. The 
strain of the weight of the body then falls on the ligaments binding the bones 
together and, as these are not sufficiently elastic to bear the extra strain 
for long, they stretch, and in time the bony arch becomes depressed", and when 
the condition has persisted for some time the foot becomes stiff and rigid. 

The symptoms of flatfoot. The condition may be acute, subacute or clinic 
and the symptoms will vary with the condition present. Acute flatfoot is 
painful; the usual sites of pain are the dorsmn, the inner side of the foot 
and the calf of the leg. The foot may be swollen, tender and hot. In some 
cases the pain is so severe that it involves the whole foot and the patient 
develop an awkward gait because he tries to walk on the outer aspect 
of his foot in order to get relief. Walking in this strained position causes 
the legs and back to ache. 

Treatment. Rest is necessary whilst the foot is swollen and very painful. 
Massage and exercises are then ordered, to restore the tone to the muscles 
and enable them to raise and maintain the structure of the bony arch. 
Manipulation — ^when the foot is rigid it is manipulated in order to make all 
the joints supple and pliant, and this may be done under a general 
anaesthetic or without one, according to the amount of rigidity present 
and the wish of the patient. 

Some surgeons advocate slight elevation of the inner side of the sole of 
the boot in (uder to assist invernon of the foot whilst the function of the 
muscles is being restored; others consider it better not to have any support. 



»LATFOOT 773 

V(^ li^d and v^umodic fktfoot h treated by forcible wrenching of the 
foot into invernon, mid fixation in plaster of paris for several weeks in 
order to overcome the spasticity by prolonged stretching and rest. The 
foot is then treated by massage, and flatfoot exercises are etnployed to 
train the patient in the correct use of the foot. 

Oa^oot or pea cavtta is a hollow foot. There is exaggeration of the 
normal arch. The tendon of Achilles is usually contracted in clawfoot. 
This condition may be congenital or it may be acquired as the result of 
injt^ or because of slight paralysis of the dorsi«flexors of the ankle. 

The tnatmerU depends on the severity of the contracture of the structures 
in the sole of the foot. In slight cases manipulation is carried out to stretch 
these, though more severe cases may require operation. After manipulation 
of the foot, masssage is employed and exercises given to teach the patient 
control of the movements of his foot. 

The extensor tendons to the toes become contracted in severe cases of 
clawfoot, especially the tendon of the great toe. Tenotomy of the tight 
tendons is umally poformed at the time the foot is manipulated. 

Morton’s metatarsalgia is a painful condition of the firont of the foot 
due to depression of the anterior transverse metatarsal arch. The front 
of the foot looks broad and wide and there is a concavity on the dorsum, 
behind the toes, where the foot should be convex. Corns and callosities 
form on the ball of the foot over the heads of the metatarsal bones. The 
digital nerves are compressed between the bones, causing great pain. 

Tlie treatment varies according to the severity of the condition. Mani- 
pulation of the foot, followed by massage and exercises, may be sufficient 
to cure it. In some cases a metatarsal pad is worn in the shoe; it forms a 
little convexity and is placed behind the metatarsal heads and the patient 
is encouraged to employ gripping or clawing movements of his foot over 
this pad. 

Very severe cases are treated by operation; the heads of some of the 
metatarsal bones are removed, but although this may relieve the pain it 
often results in an ungainly awkward gait, and it is a measure wfiich the 
surgeon considers only as a hkst effort 

Hallux valgus is a deviation of the great toe, outward, either over or 
tmder the other toes, and this causes a bunion to form — an adventitious 
biusa under the skin over the joint which becomes inflamed and painful. 

Unfortunately hallux valgus is a very common deformity of the foot; it 
may affect one or both feet and is due to the wearing of unsuitable shoes 
early in life. It is the duty of all persons who have charge of children and 
young people to see that their shoes are always long enough. A short shoe ' 
18 one of the commonest causes of bunion. 

The treatment is to manipulate the toe and if possible to teach the patient 
control of it in movements of abduction; this is raMy successful because 
the muscles which perform abduction are wasted and the amount of 
patience needed for success does not seem to be forthcoming. The next 
ctegree of treatment is to excise the bunion and perhaps a little of the bone 
(ff the head of the first metatarsal. In more severe cases it is necessary 
to excise the head the first metatarsal. After this (operation the patient 
is kept in bed for a fixtnight; then the stitches are removed and he is 
taught to walk, and to bear weight on the great toe; this is very important, 



774 ORTHOPAEDIC IfURSlNO 

othorwiso he will devdop im a’lA^cward ambliitg abcfflaig gait 'M^uch will 
]%nUt in strmn on tibe knee and hip. < 

Hallux ligidus is a condition allied to hallux valgus. The great toe is 
ri^d in the attitude of plantat^fledon and cannot be doni-^flexed, so that 
it is in the way in walking and subject to constant injury. It is a condition 
in which wthritis^ of the joint cotmnonly occurs which is probably 
rheumatic in origin. 

Hammer toe is often associated with hallux valgus; it may also be met 
in cases of fiatfoot and clawfbot and it may be congenitid. The proximal 
interphaiangeal joint is dorsi>flexed and the distal one plantar-nexed. It 
may be treated by manipulation and tenotomy of the contracted tendons; 
in severe cases an operation is necessary. 

DEFORMITIES OF THE VERTEBRAE COLUMN 

Deformity of the vertebral column is usually postural in origin. Kypho- 
sis may arise as the result Pott’s disease (see p. 782). Infante parsdysis 
by affecting the tone of the muscles of the trunk may give rise to any of the 
known deformities of the spine. 

Scoliosis is a lateral curvature of the vertebral column. It may occur 
to either side and may involve the whole of the column or only part of it. 
A curve to one side, right or left, in one region of the column may be 
compensated by another curve, to left or right, in a r^on either above or 
or t^ow it. The illustration, fig. 293, p. 765, shows a right dorsal left 
lumbar scoliosis. 

Treatment is by means of massage and exercises; the manipulations which 
are used aim at stretching the muscles over the concavities, and stimu- 
lating those over the convexities to contract and shorten. The exercises 
employed are directed at obtaining expansion of the chest on the concave 
side by means of breathing exercises and by teaching side bending to the 
convex side in order to tone up and shorten the stretched mu^cs. In 
-advanced cases, such as that shown in the illustration, correction of the 
bony deformity is attempted by stretching and manipulation of the verte- 
bral column and thorax, and a plaster of paris jacket is applied. 

Kyphosis is a round back — a deformity in which the vertebral mines 
are directed convexly backwards. It may ^ loc^ized, as occurs in Pott’s 
disease when the bo^es of the diseased vertebrae collapse and the spines 
form an acute angular curve, convex backwards. 

Occasion^y a total backward curve is seen, due to osteochondritis, the 
patient being doubled up and unable to straighten himself. A less severe 
kyphosis is shown in fig. 296, p. 766. This one was due to bad habits 
of standing owing to debility — at first the normal physiological curve of 
the dorsal region became exaggerated, die condition then got worse and 
the back became rigid. This case was stretched on an Abbott’s frame and 
treated in plaster of paris jackets, and given massage and exerciSM later. 

Lordosis is a hollow bade. Some degree lordosis is seen in fig. 297, 
p. 766.. This is compensatory to the kyphosis present m the case 
shown. Lordosis is due to the adoption of bad staling positions which 
may be due to weakness of the aMmninal and gluteal muscles^ or may 
occur as the result of some otho* defisnnity, as in die case shown. 



OEFORMITlBSiOF T8K ygaTfiARA). COLUMN 775 

, .It Dsay bQ treated by exercises or by the application, of plaster of paris, 
cotnl^ned with exercises. . 

THB DEFORMITIES OF RICKJBTS 

Rickets is a defici«icy disease of which the early manifestations are 
described on p. ago; The drformities which arise in rickets arc due, in 
some cases, to die bearing of weight on bones which are soft, and in other 
instances to enlargement of the epiphyses of the long bones. Examples 
of the latter are seen in the enlargement of the wrists and ankles, where 
two long bones lie together, and in the protuberances at the anterior ends 
^ the ribs, described as the rickety rosary. 

Deformities of the head. The head may be square, the eminences of 
the frcmtal bones being seen as enlarged b^es on the forehead, and it 
should be remembered that the fontanclles arc late in closing in rickets. 

Deformities of the trunk. The chest has a constricted appearance 
from side to side. The enlargement of the anterior ends of the ribs has been 
mentioned. The sternum may be projected forwards producing a ‘pigeon 
breast*. The lower ribs arc everted over the abdomen, which is usually 
large and distended. A groove in the axillary line is described as Harrison’s 
sulcus. 

The spine may appear flat; or it may present a long round back; or some 
degree of kyphodordosis may be present. Scoliosis may arise in rickets and 
the jielvis may be deformed. In some cases the pelvis is flattened from 
before backwards, in other cases it is triradiate in shape. Either of these 
deformities may in female subjects result in difficulties m midwifery later. 

Deformities of the limbs are commonest. Bowlegs may aflect the 
tibia only or the whole of the lower limb may be bowed (as shown in 
fig. agg, p. 767). This is treated by manipulation in slight cases when the 
bones are still soft; but when the bones have hardened osteoclasis is per- 
formed, which consists of breaking the tibia over a wedge of wood. The 
limb is then put up in plaster of paris long enough for the break to heal-— 
firom 5 to 6 weeks— and the child then walks on the straightened legs. 

Knock-knee or gem valgum is a deformity in 'which the knees are 
directed inwards towards one another (as shown in fig. 2g8, p. 767). 
In slight cases a knock-knee brace may be worn to correct the deformity 
and help the child to walk with his legs straight. Manage and exercises 
will help by teaching control of the movements of the knee. In severe cases 
osteotomy of the femur, just above the knee joint, is performed; the limb 
is put in plaster of paris for about 6 weeks, massage and exercises are then 
employed and the child walks. 

Knock-knee may also arise as the result of abnormal overgrowth of the 
lower end of the femur at adolescence— the treatment of this being the 
same aa when due to rickets. 

Coxa vara is a varus deformity at the hip joint. In a varus deformity the 
part is always directed towards the middle line, in a valgus deformity it is 
directed away from this point. 

In cpxa vara the lower limbs are adducted towards the middle line; the 
pdvis looks wide and there is lordosis; the child walks with an awkward 
wadefling gait. 

The treatmmt is traction by means of extension if the bones are still soft; 



776 ORTB<}PASOI€ NURSINO 

but if hardened the deformity is corrected by osteotomy of the femur, 
which is performed either across or just below the great trodianter the 
femur, and folloMred by fixation in plaster of paris with the Iknb well 
abducted until the parts have healed. 

Coxa vara may also be due to injury to the epiphyses at the upper 
extremity of the femur or to deformity resulting firom fracture of the femur. 

Deformities of the arm can occur in rickets thoi^h, as weight is not usu^y 
borne on the arms, these are rare. The bones of the forearm may be bowed 
if the child crawls. 


DEFORMITIES DUE TO DISEASE OF THE CENTRAL NERVOUS 

SYSTEM 

Infantile paralysis is the cause of a lai^e percentage of crippling 
deformity in this country. The coiklition is difficult to control, because, 
as well as loss of power of muscles over joint movement, there is lack of 
development of the affected limbs and consequent loss of balance. There* 
fore paralysis of the muscles of a lower limb may result in deformities of 
hip, knee and foot, and may affect the tnmk as well, causing scoliosis. 

In infantile paralysis the muscles are not primarily affect^, as it is a 
disease of the central nervous system; the motor nerve cells in the anterior 
horns of the spinal cord are affected, many of them are destroyed and, 
as the result of this, communication between the voluntary muscles and 
the nervous system is lost; the muscles cannot contract, they are flail, and 
the deformities which arise are numerous. 

The syn^toms present during the acute stage of this disease are described 
on p. 410. As a rule the description of the symptoms of infantile 
paralysis is divided into a stage of onset, a stage during which the amount 
of paralysis which will accrue is seen, and a further stage when, as the 
result of this, deformities may arise. It is with the last stage that ortho* 
paedic treatment deals. 

The treatment during the acute stage is rest. The application of rest is of 
primary importance and it must be carried out in such a way that neither 
can the affected parts be moved nor the patient even be able to attempt 
to move them. To obtain this result the whole of the affected part and the 
joints above and below it should be encased in splints or in plaster of 
paris, and these should not be removed for any purpose until firom 2 to 4 
months have elapsed. The p>ositions adopted snould be neutral so that 
neither one nor another group of muscles is being stretched, but that all 
are at rest. 

At the end of this time, the affected parts may be examined in order to 
determine the damage which is present; some muscles or muscle fibres 
may be entirely devcod of nerve supply, while others will be only partially 
deprived. For a further period splmti^ is employed, in order to keep the 
affected muscles at rest; it is now advisable to adopt a position of greatest 
rest for the flail muscles rather than a neutral position. If for examine the 
dorsi*flexors of the foot are flail, the foot may be splinted in slight dorsi* 
flexion so that these muscles are as relaxed as pocuble. 

After the first 2-4 monflu of absolute rest, massa^ may be enjoyed 
in order to aid the circulation of blood and lymph in the affected pa^. 
Electricity is not used, as it would only stunulate the contractkMi 
muscles, which is contraindicated as long as rest is coiuidered necessary. 



DEFOItMintBS DUB TO DUfeASE 777 

During a Jurthtr period of from one to Um years after the initial attack, sfdint 
treatnmt and massage and re-education exercises are employed. At the end of thu 
time the position is again reviewed, some musdes may be found com- 
pletely flail while others will have wholly or partially recovered. 

To compensate for the muscles which are not acting, some mechanical 
device may have to be worn permanently; or an operation may be under- 
taken either to tra^lant healthy muscles to take the place of those not 
acting or arthrodesis of one or more joints may be performed so as to limit 
the movement possible at a joint and so stabilize the joint and improve its 
general useflilness. 

Spastic-paraplegia is a disease which affects the control of the nervous 
impulses passing to the muscles; it is a condition which in its effects is 
exactly contrary to that caused by infantile paralysis. In spastic paralysis 
there is a functional increase of the nerve supply to the muscles, and the 
affected parts are rigid and spastic and the tendon reflexes exaggerated. 

This condition may be seen in both children and adults — ^in children, 
when it appears early in life, due either to come congenital abnormality 
or to injury at birth, it is described as Little's disease. The condition may 
not be noticed until the infant begins to walk, when he will be found to 
make spastic erratic movements, appear very frightened, and clutch at 
his mother’s skirts and at the furniture near him. 

When the spasticity affects the lower half of the body — ^both lower 
limbs — ^it is called paraplegia', when one side only is affected, hemiplegia (sec 
also p. 408) ; when only one limb is aflected, monoplegia; and when limbs 
on toth sides are affected — for example one arm and both legs — it is 
described as diplegia. 

In the care of cases of spastic paralysis certain points have to be considered. The 
child is very likely to manifest some degree of mental deficiency; he may be 
irritable and ill-tempered, or else very placid, not moved by anything. In 
spastic paraplegia the typical scissor gait will be seen; the child will 
attempt to walk on his toes, with his knees flexed and his thighs so tightly 
adducted that one leg is thrown across the other in the movements of 
walking. When an arm is affected it will be held tightly to the side of the 
body, with the elbow and wrist flexed and the forearm pronated. 

On examination the adductor muscles of the hip joint, the flexors of the 
thighs, and very often also the tendon of Achilles, all be found tightly 

contracted. 

The surgical treatment most commonly undertaken to correct the spasticity 
is division of some of the nerves passing to the muscles — Stoeffel’s operation. 
Other measures include stretching the contracted muscles by splinting 
and division of the tightened tendons and strands of muscle fibres by 
tenotomy, or excision of them by open operation. 

Stoeflfel’s operation is considez^ to be the most successful method, and 
the post-operahve care is not difficult as subsequent stretching and splints are 
not necessary. The child should^be trained to me his limbs quietly, slowly 
and rhythmically. He will need a lot of encouragement and shovdd never 
be ridiculed or idlowed to get tired. 

When* the patient is also mentally deficient he should be made to].feel 
that he^is wanted and should be encouraged to take part in die play of 
other children. Such children are often timid and easily frightened. They 
may have difficulty in eating and should be trained to me the ordinary 



ORTHOPA«J>IO WVIWINO 

feeding utensils and tp e»t Qioe}y, not bolting their &od; when there is 
incontmenoe of urine and &ec<!s^ attempts should be ma^ to overctnae 
this, by giving the child urinal and bedpan at reguter and fkiriy frequent 
intervals in cwder to teach him proper control if possible. , 

Birth palsy is a tenn used to describe a state of paralysis produced by 
injury at birth. Any spastic paralysis may be due to this causcj the injnry 
usually affects the ti^er motor neurones (see p. 407), so that the h^ion 
results in spasticity. Erb’s pd^ is one type; it affects the muscles of the 
shoulder girdle resulting in adduction of arm and pronation of hand. 

The treatment is on the same lines as described for spastic paralysis. 

DEFORMITIES ARIEINO FROM CONTRACTURE OF THE 
SOFT STRUCTURES 

In the notes on congenital deformities, and deformities due to paralysis, 
it has been suggested that any persistent mal-position at joints will give 
rise to anatomical changes which will eventually result in deformity. In 
the case of injuries where healing takes place by scarring and the formation 
of fibrous tissue, as in bums and injury to muscle, this danger must bp 
constantly borne in mind. 

The injuries arising as the result of infantile and spastic paralysis have 
been enumerated above. In addition two contractures which are specially 
designated may be mentioned: 

Dupuytren's contracture occurs for the most part in middle-aged 
men, and more especially in those who follow such occupations as may 
cause constant friction on the palmar surface of the hand, as in the case of 
cobblers. Contracture of the fascia in the palm of the hand begins as a 
small fibrous band, the skin over this becomes puckered and the ring finger 
and sometimes the other fingers are drawn down in flexion. 

The treatment is to excise the contracted fibrous structure by an open 
operation on the palm of the hand. 

Volkmatin's contracture occurs as the result of injury to the muscles 
of the anterior aspect of the forearm. The usual hisioiy is that in the 
treatment of an injury to the elbow the arm was put up in acute flexion 
of the elbow. This position may have interfered with the blood supply 
so that the muscles on the front of the elbow were deprived of nourish- 
ment; they become degenerated in consequence, fibrous tissue femns, and 
this ccmtracts so that the fingers eff the hand are contracted in flexion. 

This condition is always preventable, but when it occurs it is inuaUy in 
children, who may not complain of pain due to pressure. It is essehti^ to 
watch with care for swelling of the fingers in any case of injury to die arm, 
forearm or elbow. If there is disappearance of the pulse at wrist this 
indicates serious ot»truction to the flow of Mood into the fingers. In sudh 
a case the need for relief of pressure is mgent, and a nurse should get a 
doctor at once; if he caimot come, she should cut die bandages or die 
plaster of paris over the bend of the elbow, and keep the patient waiting 
and restiz^ so that the posidem of the elb^ is not interfered widi untu 
the surgeon can come, readjust the position of the arm and make a firesh 
application of plaster of pans. 



Chapter 48 

Surgical Tuberculosis 

(See also Chapter 31) 

TiifecHon fy the tubercle baciUtts — Changes in the tissues — A tuberculous abscess— 
Tuberculosis of glands— Tuberculosis of bones and joints— Tuberculosis of the 

genito-urifiary system 

T ttbercuknis is an infective disease caused by the tubercle bacilltw 
which was discovered by Koch in 1882. The disease affects certain 
parts of the body, principally the lungs, bones, jeunts, meninges, 
lymphatic glands and the kidn^, prostate gland and testes. 

The tubercle bacillus is a minute oiganism about 1/10,000 of an inch 
in length and can only be seen by the aid of a high-power microscope. It 
possesses a stout resistant capsule which makes the organism difficult to 
destroy by chemicals; but fortunately it is eeisily destroyed by exposure 
to heat — even quite moderate heat — and it has been found that exposure 
of infected articles to the sun’s rays is sufficient to destroy the organism. 

Infection is spread by means of discharges, secretions and excretions 
from the lesions of tuberculosis in infected p>ersons. The disease is largely 
disseminated by means of sputum which becomes dried and is carried by 
particles in the air, to be deposited on articles of food, or inhaled by per- 
sons breathing the infected air. 

Another source of infection is dairy produce from infected cattle, in the 
forms of milk, butter and cheese; by this means bovine tuberculosis is 
spread, and children are frequently infected in this way. A rarer form cd 
section is by inoculation, which occurs when the abraded skin is infected, 
and may result in lupus. 

Inhalation. When tubercle bacilli are inhaled the organisms may be 
arrested on the mucous surface of the pharynx and tonsils; from this area 
infi:x;tion may be conveyed by means of blood and lymph to the local 
lymphatic glwds in the neck. The organisms may enter the lungs, setting 
up pulmonary tuberculosis (see description of this disease on p. 481), 
or it may get into the lymph stream and be conveyed to the lymphatic 
glands in ffie thorax <»: be spread by means of the blood to distant parts 
of the body and infect the bemes, joints or meninges. 

Ingestion. When tubercle bacilli arc taken in wiffi food or fluid they may 
again become arrested by the tonsils; or, entering the stomach and intes- 
tine, may cause infection of the lining of the intestine (tuberculous 
enteritis). By means of the lymph they may reach the mesenteric glands 
in the abdomen, causing tabes mesenterica; and, freon an infected gland 
the petitonemn may become infected and tuberculous peritonitis follow. 
Again, the organisms may enter the blood stream and be conveyed by it to 
cause disease in some distant part, such as in the bones, joints, lungs or 
menii^^ 

Changes in the tissues. As the result of infection by tubercle, the 
tissues are irritated and a certain amount of reaction occurs; this may give 
rise to proliferation of <^ls and destruction of some of the tissues. A very 

779 



780 SURGICAL TUBERCULOSIS 

typical change is described in the fbrmaticm tubercles. A tubenk k a 
collection of cells vriiich takes the form of a greyish mass large enough 
to be visible to the naked eye. It is composed by a little group of tubercle 
bacilli, surrounded by leucocytes, giant cells and epitheloid cells. This 
group of tubercle bacilli is antagonistio to the tissue in which it lies, and 
me subsequent changes which occur depend on whether the tissues are 
resistant and can overcome the activity of the organisms, or whether the 
organisms are sufficiendy virulent to cause breakdown of the tissues, and 
spread of the disease. 

Caseation. The tuberculous lesion now established usually extends 
farther by development of a number of tubercles and their coalescence 
into a large mass; the centre of this becomes dry and crumbling Ike 
crumbs of cheese — hence the term caseation. In this state the tubercle 
bacilli are still separated from the surrounding tissue and their destructive 
action is arrested; after this stage either he^n^ Mull take place in the 
changes described as fibrosis and more rarely calcification (see note below) ; 
or the mass will soften and liquefy, indicating spread of the disease; the 
softened mass forms a cold abscess — a term us^ to describe a tuberculous 
abscess, which is subacute in character. 

Ylhcn fibrosis takes place a large number of fibrous tissue cells form, 
contraction and scarring occurs and the area invaded by disease germs is 
thus rendered innocuous; it ceases to function and becomes a sterile mass, 
functionally separated from the remainder of the organ in which it lies. 

In calcification, lime salts become deposited in the fibrous tissue formed 
in the area of the tubercle and hardening takes place. 

A tuberculous abscess is the result of the liquefaction into pus of the 
caseated tuberculous material. This collection of pus is not accompanied 
by the usual signs of inflammation — ^heat, redness and pain — and it is 
therefore called a ‘cold abscess’. When mixed infection occurs and the 
tuberculous abscess is complicated by the presence of other pyogenic 
bacteria, such as staphylococci and streptococci, then the ordinary 
changes of inflammation occur. 

A tuberculous abscess consists of a central liquefied mass, surrounded 
by an area which is caseated; if the disease is progressing, fur^er liquefac- 
tion takes place in the walls around the pus and so the abscess increases 
in size. 

Another interesting feature about a tuberculous abscess is that the 
direction in which it may spread is determined by the anatomical 
arrangement of the tissues in which it has formed, and to some extent by 
gravity. In the case of a psoas abscess for example; the tuberculous lesion is 
usually the dorsal votebrae; the abscess collects in the psoas muscle 
because the pus tracks down along the side of the vertebral coluinn and 
along the sheath of the psoas muscle imtil it cotnes to the surface just 
above Poupart’s ligament at the groin. 

As a tuberculous abscess reaches the surface fluctuation of the pus 
contained in it is noticed; if left untreated die abscess may op>en spon- 
taneously, the cavity of the abscess will thus usually become tweeted by 
seconda^ oiganisms and a persistent sinus be left, so that healing is 
delayed or prevented. 

The treatment of a tuberculous abscess depends on its size; in some cases, 
if left alone, and the general health of the patient is -improved, it will 



SUROiCAL TUBBRCULOSIS 781 

disappesup; if it i&cricases in size and beconuM superficial some sui^eons 
advocate its evacuadon, either by means of a hoUow needle with whidh 
die contents can be aspirated, or by means of a small incision. The abscess 
cavity may be filled with bismuth and iodoform paste which is antagonistic 
to the action of bacteria, and so healit^ of the cavity may be stimulated. 
Whm the contents are thick and cannot be evacuat^ the cavity may be 
curetted^ and .the wound is packed and allowed to heal from the bottom. 

In some cases applications of radium have been found of value in 
sdmulating absorption of fluid and repair of the tissues in cases of glan- 
dular abscess. 

TUBERCULOSIS OF GLANDS 

Tuberculous disease of the lymphatic glands occurs with comparative 
frequency, especially in children and young people; the lymphatic glands 
in the neck are often affected, as they probably arrest the tubercle bacilli 
which get into the lymphatic stream when inhaled, or ii^ested with food. 
One gland or several glands may be infected; the glan^ swell and the 
patient may complain of a little stiflhess of the neck due to interference 
with the action of the muscles in the neighbourhood of the enlarged gland, 
or the swelling may be the first indication. The ordinary changes described 
on p. 779 occur and, if liqudaction results, an abscess forms (see 
previous page). 

The treatment varies according to the state of the condition when seen 
by physician or surgeon; at first the general care of a tuberculous person 
is applied; the child is allowed to be in the fresh air as much as possible, 
and is given a diet of high calorie value supplemented by cod-liver oil. 
(For details of the general care of tuberculosis see p. 481). 

Swelling of the glands may be treated by radium or X rays, and if an 
abscess occurs it may be aspirated or evacuated in some other way. 
Extensive disease of the glands may need excision of a group of them and 
of the adhesions which have occurred in the immediate neighbourhood. 

TUBERCULOSIS OF BONES AND JOINTS 

Tuberculosis of bone commences in the marrow or periosteum and is 
transmitted to the bone in the immediate neighbourhood, and in many 
instances the joint in the vicinity becomes infected. Tuberculous periostitis 
rives rise to a subacute swelling over the affected bone; tuberculous osteomye- 
litis is of very slow onset and may not be discovered until the bone is 
considerably affected and the inflanunation has spread to the surface of it. 
Tuberculous dactylitis is the occurrence of osteomyelitis in the bones of the 
hands and feet, the carpus, metacarpus, tarsus, metatarsus and phalanges; 
the fingers become spindle-shaped and swollen, abscesses arise and 
sinuses form. 

Tuberculous disease of joints usually begins in the synovial mem- 
brane, or the marrow in the cancellous tissue of the ends of the bone. The 
synovial membrane is thickened, it becomes adherent to the hyaline 
cartih^ covering the ends of the bones which enter into the formation 
of the joint affected; the cartilage becomes ulcerated and tuberculous 
infiltration of the cancellous tissue takes place, resultii^ in destruction 
which is described as caries. Extensive destruction of bone may so interfere 



yds 8UROIGAI. f U&E'RCrdt.OSIS 

with futKtion of die joi^ that a pathological dido^doti oocutis. A 
considerate amount of fluid CollecUi in the joiitt causing die swCllihg 
whkh isoflen noticeable and by smetdiing the Kgaments predhsjKMes to 
pathological didocation. ' 

Tuberculosis of the spine or Pott’s distiise be^nut at the lion* of the 
bodies of the vertebrae and which CrumWe as decay occuw giving rise 
to the deformity kyphosis oT angulation of the spine, llie deformity 
present in an advanc^ case is shown in flg^ spi, p. 764. 

The symptom <utd signs of joint tuberoulosis may be dassifled as genor^ 
and local. The patient may, however, exhibit a few constitutional 
symptoms. 

A typical history often elicited is as follows— The mother might have 
notic^ the child was slighdy unwell, that he did not slew at mght or 
perspired during sleep, he may have exhibited some lade of appetite and 
lost a little weight. 

As time went on, he refused to play and, if the lower limb affected, 
began to walk with a slight limp; this may have been attributed to some 
blow or kick the child had received months or years previously. The 
mother might say that the child cries out in the night and, when she un- 
covers him, she observes that his hands are protecting the suspected Joint 
as if to prevent pain. At this pieriod the child may have a sUg^ rise of 
temperature in the evening, the mother may notice that he is a little 
feverish and perspires a good deal during the night so that his bedclothes 
are wet in the morning. 

On examining the limb, it might be foimd to be slightly w^ted and the 
joint somewhat swollen. When asked to move the joint it will be noticed 
that the child guards it carefully and moves it slowly and deliberately, 
and that movement obviously causes some pain. 

If the child has not been treated before this stage has been reached, 
he will develop a rigid joint, which in time will become fixed in a position 
of deformity; in the case of a knee, the joint will be flexed; the mp joint 
may be flexed and adducted. 

. Treatment. The general treatment for all cases of tuberculosis will be 
employed; the patient should be nursed in die open air if possible and 
given a liberal nourishing diet; he should be weighed regularly and will 
gain in weight if the treatment is successfuL 

The local treatment is rest in the first instance, and many cases recover 
as the resiUt of carefully applied rest If the joint is deformed as the result 
of muscular contraction, me defomaity is carefully reduced, the Imb 
immobilized on a splint aided, if necessary, by the application of extension. 

In severe cases in which tl^e is bony drformity operation may have 
to be undertaken to excise the diseased parts and so shorten the period of 
rest necessary. 

In the nursing care of cases of joint tuberculosis the position of the limb 
obtained by the surgeon must be maintained; the nurse should see that 
die splint is kept in position and that any extension app^tus is in good 
worung order and docs not slip or move. She must realize that in order 
to maintain accurate immobilization of the joint she may have difficulty 
in moving the patient and all her nursing nteasures must be sacrificed, if 
necessary, to maintaining the degree of immobilization and rest the Sur- 
geon desires. She should tell him her difficulties, and he will Aow her 
how mudi she may move the patient without harm. 



TUBERCULOSIS OP BONES AND JOINTS 783 

It IS necessary to observe the patient carefully for improvement in his 
general condition, and to see whether the treatment which he is under- 
goi^ is resulting in improvement of sleep. The nurse should watch for 
crying or restlessness at night and be able to state whether or not this 
symptom is improving as it should, now that the diseased parts have 
been put at test by inimobili^atiDn. The fact that this symptom does not 
improve will show that the rest is not sufficient and the surgeon ought to 
to be informed of this. 

TUBERCULOSIS OF THE GENITO-URINARY TRACT 

Any part of the tract may be infected; in the majority of instances the 
kidney is the part first involved. The tubercle bacilli reach the kidney 
in the blood stream and usually one kidney becomes affected. The usual 
chatiges take place and the substance of the organ is destroyed, while an 
abscess may form giving rise to pyonephrosis. 

Symptoms a&d signs. The first symptom complained of will be fi:c- 
quency of mictilrition. On examination the urine may contain blood, 
albumin or pus, and careful investigation should be made for the presence 
of tubercle bacilli. The urine should be measured as polyuria is sometimes 
present. 

The patient may have a dull aching pain in the loin of the affected side, 
which is not relieved by rest. As time goes on there will be a rise of tem- 
perature in the evening, the patient wiil sweat at night, complain of loss 
erf" appetite and will lose weight. By this time he will present the charac- 
teristic appearance of one steering from toxaemia due to tuberculosis. 

The bladder will eventually become infected, cystitis will be present and 
the discomfort of the patient is greatly increased by this. 

The treatment of a tuberculous kidney is to remove it, but the 
functioning of the other kidney must first be investigated, for fear lest it 
also is diseased. The existence of pulmonary tuberculosis or other lesions 
adds much to the gravity of the prognosis. (For the preparation and post- 
operative nursing of nephrectomy, see p. 676.) 



Chapter 49 

Rheumatic Affections of Joint and Muscle 

Symptoms and treatment of arthritis — Gold therapy — Muscular rheumatism. {Acute 
rheumatism is described on p. 444.) 

iK rthritis deformans, rheumatoid arthritis, toxic atthritis, ostco- 
arthritis and hypertrophic arthritis arc a few of the titles used to 
JL describe one form of chronic joint affection or another. Arthritis is a 
disease which may occur at any age; in children it is known as Still^s 
disease. In adults it may occur in either sex and unfortunately it attacks 
quite young persons, in young women the form known as rheumatoid 
arthritis which commences in the small joints of the hands and wrist is 
most prevalent; whilst men more often than women suffer from the type 
known as osteo-^artkritis which commences in one of the lai^c joints as in 
the shoulder, hip or knee. Rheumatic arthritis is a serious crippling 
disease which is responsible for a lai^ percentage of the total disablement 
of workers in this country. 

Of the cause little is known but many theories are put forward for con- 
sideration. Some consider the condition is due to infection cither by b. 
coli or by one of the non-haemolytic strains of streptococcus. The infected 
focus may exist in the teeth, tonsils, cranial sinuses, gallbladder, ^pendix, 
colon or in the genito-urinary tract. In some a septic focus is found, in 
others if present it fails to be detected. A few suggest that the disease is due 
to an endocrine deficiency resulting in faulty metabolism, and adherents 
of this school of thought go so far as to describe the condition as ‘non- 
infective’. Others again consider that rheumatic arthritis depends on 
some inherent familial tendency and that given suitable circumstances 
the disease will develop. Predisposing factors may include anything which 
lowers the resistance of the body, such as anxiety and worry, mental 
strain, sustained fatigue, and exposure to damp and cold. 

Onset and Symptoms. In the majority of cases the onset is insidious 
but cases are known in which the disease began suddenly. The distribu- 
tion is symmetrical. In rheumatoid arthritis the proximal intcrphalangcal 
joints of the fingers and the mctacarpo-phalangeal joints are firet affected, 
the knees, ankles, elbows, shoulders and hips becoming affected later; in 
some the spine is involved, in other cases it escapes. 

The affected joints appear swollen and the fingers become fusiform in 
shape; the knuckles are prominent and enlarged and the wrist sub- 
luxated. There is a tendency for the fingers to deviate to the ulnar side as 
shown in fig. 300, p. 768. During the earliest phase of the disease there 
is often considerable tenderness, and movement causes severe pain; the 
skin over the joints is tense and glazed and the circulation is poor. Wasting 
of muscle is a feature of arthritis because movement is limited, the joints 
stiffen and are difficult and painful to move, and movement is accom- 
panied by creaking and cracking. The grip of the hand gets weak. As the 
disease progresses fibrous adhesions form which cause further limitation 

784 



MWECnONS OF JOINT ANO MUSCLE 785 

noovemmt, and ib some severe and long«standing cases bony chsuiges 
may result in ankylosis. 

The disease scons to progress to a point, more or less advanced where 
it becomes arrested, and one of the aims of treatment is to arrest the pro- 
gress of the disease at the earliest possible moment, in order to preserve 
the function of the joints and prevent deformity. 

Some general symptom are present in most instances; there may be a rise 
ui temperature, and anaemia, the patient often looks ill and loses weight, 
sweating of the dcin is notice^e particularly of the palms of the hands. 
Pain arid stiffness cause sleep, to be interrupted and the patient gets very 
tired and exhamted. 

TREATMENT OP RHEUMATOID ARTHRITIS 

The aim of treatment are to effect arrest of the disease at the earliest 
possible moment, to relieve pain and to prevent deformity. As regards 
general treatment, rest in bed is advised, a nourishing diet is provided, any 
impairment of digestion should be investigated, the bowels should be kept 
actii^ regularly and anaemia and any endocrine deficiency noted and 
treat^. 

Sleep is essential and as the patient is often kept awake by pain and 
disconifort, immobilization of the affected joints at night may help, and 
the administration of some form of salicylate may relieve pain in joint 
and muscle. Sedatives are rarely ordered as there is a danger that the 
patient may learn to depend on them and develop the habit of taking 
sedatives. 

Many drugs have been tried, some are palliative and others of little 
value, sera and vaccines ,have proved useful in some cases and protein- 
shock therapy in others, and recently the injection of gold salts has been 
found beneficial in selected cases (see p. 786). 

Local treatment. During the acute phase of the disease when pain and 
tenderness are marked, inunobilizadon of the affected joints is necessary. 
Very light splints only are advisable and these shoidd be removable; 
bi-valv^ light plaster of paris splints are best. A splint which is removable 
enables the joint to be moved as soon as the acute phase is beginning to 
abate and at the same time it provides the immobilization necessary in 
the intervals between treatment. 

Heat in some form or another is probably the most valuable local treat- 
ment. It may either be employed with the intention of producing a good 
skin reaction, as when vapour baths, brine baths, foam baths, anti- 
phlogistine mud packs and radiant heat are used. Or it may be applied 
to penetrate the tissues, as when an electric current is employed by means 
of diathermy, inducto-thermy and short-wave currents. 

Applications of heat are valuable in increasing the blood supply to the 
part treated and help to relieve pain; maintain the tone of the tissues; 
prevent wasting of muscle; and render the joints more supple and so 
facilitate movement. Heat may be used independently of any other form 
of treatment, or it may be employed before some form of manipulation 
such as mass^e and passive movement, and also before active exercise, 
as movement is easier and can be more comfortably perfonned when the 
blood supply to the part has been improved by inducing hyperaemia 
which is one of the effwts of heat. 



786 AinrBQTIOlVB OF JOINT AND MUSOLB 

Mmsag$ and passivt mmhtra ZEiay ^ emj^oyed after the acute lahaas) 
gentle movements are given first, progressing as pain is relieved, lilie work 
must be very carefully graduated so mat any reaction wluch would result 
in return oT the acute symptoiiis is avmded. 

Active mvmcfU is essentisu as soon as the acute j^ain is relieved’ in order 
to prevent rigidity and muscle wasting, and to maintain the function of 
the affected joints which so quickly get stiff if they are not moved. Active 
movement is more valuable than massage and pas^e movement and the 
patient should be encouraged to move his joints many times during the day 
m between the visits of tlm masseuse. He may be given smaU interesting 
recreations which necessitate fine movements of the fingors and hand, 
such as knitting, basket weaving, playing patience with small cards and 
so on. 

Sometimes the visiting masseuse uses the faradic current as an adjunct 
to her work to stimulate the contraction of muscles, and the patient 
should take an interest in the contraction of individual muscles ana inner* 
vate these as the current is applied, and then, at intervals during the day, 
voluntarily contract these, as by so doing he will improve the tone and 
power of the muscle. 

Prevention of deformity is important, the means employed by splinting, 
the slretdiing of tendons which may be getting tight, and constantly per- 
forming movements of the affected joints have been indicated. 

Forcible tnanipulaHon may be necessary in some cases. In those, for 
example, where fibrous contraction had ocemred before the patient 
presented himself for treatment; and in cases where limitation of further 
mcrease in the restoration of function is reached. Some physicians recewm- 
mend the very gradual breaking down of adhesion^ others progress more 
rapidly. In either case it is essential that any manipulation penonOed is 
followed by massage and passive and active movement, otherwise adhe- 
sions will quickly form again and no good will result from the manipula- 
tion. The physician should be informed of any reaction which follows 
forcible manipulation, as he will wish to avoid producing an inflammatory 
state which could only result in the formation of adhesions. 

GOLD THERAPY 

About 25 years ago gold was first used in the treatment of puliDcmary 
tuberculosis; it has since been employed in some forms of skin eruption 
and more recently in the treatment of rhaattaknd arthritis. A number 01 gold 
preparaticHu are obuunable, and most of them are administered by intra- 
muscular injection; gold is a heavy metail and tends to accumulate in die 
system, but in order to avoid this intervals are arranged between oom^ 
of treatment to allow time for the proper excretion the gold salts. Gold is 
contraindicated \^en there is disease of the heart, liver, or kidneyS^ 

As a prelinnndiy to ^et^meitt the geitoTal condition of the patient’s health 4 s 
examined, tiic function of the kidneys investigated^ and a blood count 
made and the sedimentatien rate of the rdi blood cells noted. GoM maV 
be given either in large Or in smaU doses; when the latter method, whicn 
is more usual, is adeptedj a preparation such as alltKhrysittf may be em- 
ployed — this substance is tenildly g^ven in doSes of fiom d*oi to 0-05 of a 
gramme, at intervals of from 5 to 7 days until the patient has a 
gramme or a gramme and a half. An interval follows of fitotn 6 to 8 weeks 



SOLD THE«APY ^87 

aaaid if the patiettf » coniidered a suitaUe suited for gold, a further coiurse 
or eivefl two couraes cf t]«atme&t may follow. 

Nutting dbaeii^atkma are important, gold is a dangerous drug, and 
any mine who did not know what untoward symptoms to watch for and 
the neceSBty of reporting tJhew to the physidan \dthout dday, would ^ 
guilty of culpable hoglcct. As soon as any of these symptoms are observed 
gold must be withheld until Che physician has seen the patient and n^e 
his decision, wd in the meantime the patient should be given copious 
dipdS) containing glimose. 

^ Ex/oli^e demits is the biggest danger, and the most serious compUcar 
don which arise; when fully developed the skin will be inflamed and 
wet^ung and the padent in great pain, and in order to avoid this danger 
cardul watch should be kept on me skin for any complaint of irritadon, 
the slightest sign of redness and any tenderness, as either of these symptoms 
may indicate the onset of dermadtis. Albuminuria may be the first indica- 
tion of failure of the kidneys; the urine should be tested daily in the case 
of a padent in hospital. Alteration in the character of the blood may arise 
and this might be indicated by purpuric spots or by rapid increasing 
anaemia. Impairment of digestion^ characterized by loss of appetite, soreness 
of the mouth, a dirty tongue and diarrhoea should be carefully noted; the 
general condition of health should improve under treatment and increased 
malaise, feelings of fatigue, soreness of the throat, a rise of temperature and 
restlessness are all symptoms which should be noted at once. 

The good effects likely to arise from injections of gold salts are relief of pain 
and improvement in the function of the affected Joints; combined with 
improvement in the general health of the patient, which increases as the 
patient himself notes the improvement and becomes happy and optimistic 
about the future. 

But a note of warning is again necessary. It is this: many patients 
suffering from rheumatoid arthritis have tried a number of cures which 
have been disappointing; perhaps the patient had heard of gold and has 
hoped it would be ordered for him, and anxious to persist with a treatment 
which he may have come to look upon as a last resort, he will desire to 
persist with it in spite of not feeling well, and he will try and hide his 
symptoms from the physician and nurse. When patients are attending an 
out-patient clinic for gold injections it is essential not only to question 
them about their general health on the lines already indicated, but also 
to scrutinize their appearance very carefully — the tongue, gums, mouth 
and throat should be examined, the temperature and pulse taken, the 
patient weighed, the urine tested and the skin inspected. 

At the first appearance of symptoms the treatment should be stopped. 
Glucose, liver and calcium are pven to improve the condition of the blood, 
and sometimes a physician wiU order these to be given to less robust 
patients before a course of treatment is commenced in order to lessen the 
probability of untoward symptoms developing. * 

MUSCULAR RHEUMATISM 

Inflammatory changes occurring in the muscles, fascia, tendons, 
ligaments and in the sheatiis of nerve is ofien described as muscular 
rhewnatism. Pain in the muscle is myalgia. 

The muscles most commonly affected are those of the neck, the trapezius 



7S8 >UrFEGTION8 or J<HNT AND MUSOUt 

and die sternosnastoid muscle, which may restdt in spasmodic 
and mck', the intercostal muscles whrai the pain is doNribed as 
plewroifyniai the thick muscles and fascia of the lumbar region in the back 
in lumbago. In stiff neck the inflammation may ^read to the brachial 
plexus of nerves giving rise to brachial neuritis; wd in lumbago it may 
spread to the sheath of the sciatic nerve causing sciatica. 

Treatment when the pain is acute is by rest and applications of 
warmth, either superficial applications suCh as hot stupes, antiphlogisdne, 
radiant heat, of which infi’a-red rays is one example; or heat may be 
applied by electricity in diathermy or short-wave therapy. In some cases 
the application of analgesic liniments may mve relief, as A.B.C. liniment; 
and in lumbago the application of a belladonna plaster, and sometimes 
cupping the loins may relieve stiffness and pain. 



Chapter 50 

The Nursing of Cancer Gases 

care and nursing of cancer cases — Motes on the treatment of cancer by radium 

' X^ray therapy 

I n many general hospitals nurses complete their training without 
having acquired very much knowledge of the care of cases of cancer; 
yet, if they are to be of general use to the community in the control 
of this disease they ought to know something about its early signs and the 
commonest sites where it may arise. 

^ Every nurse should be able to discuss with an inquiring patient the 
lines on which treatment of cancer is carried out and the great advantage 
to be derived from early treatment. She should be able to dispel much 
of the fear which leads so many sufferers to hide any symptoms they think 
may be due to cancer, and should ^courage all patients to consult a 
specialist as soon as their suspicions are arous^. 

The commonest sites pf cancer are the alimentary canal, the breast 
and the female organs of generation. In men the mouth is one of the sites 
most commonly affected, and the disease may begin in the lip, cheek or 
tongue. Cancer of the lip often commences between the centre and the angle; 
the neighbouring lymphatic glands soon becoming infected. In the cheek it 
may begin as a small wartlike growth. In the tongue it affects the anterior 
two-thirds, along the margin of the tongue, beginning as a small ulcer. 

Cancer of the breast may begin as a small nodule palpable when the hand 
is placed flat on the breast, or by a slight discharge from the nipple. 
Cancer of the uterus, including the cervix, begins by bleeding between the 
periods, metrorrhagia, and in older women by post-menopausal bleeding. 

Cancer of the oesophagus may arise at the junction of the pharynx and 
oesophagus, opposite the bifurcation of the trachea or near the cardiac 
end. The patient first complains of difficulty in swallowing solids. 

Cancer of the stomach usually begins with vague symptoms of indigestion. 
Cancer of the colon most often arises at the flexures, particularly the sigmoid 
flexure and rectum. This form is often not noticed until the patient 
complains of bleeding from the bowd with discharge of mucus. 

The early signs of cancer arc very insidious. A rodent ulcer for 
example may bemn as a small raised eminence on the skin, usually of the 
face sind head, vmich after a time the patient notices docs not heal, and is 
covered by an exudate, and then it may begin to^spread. A man may 
notice he has a slightly thickened area on his Up, or a Uttle ulcer on the 
tongue* A woman may discover a very smaU nodide in her breast; in some 
cases, the onset of Paget’s disease of the nipple may cause sUght discharge 
from the nipple. Irregular or profuse menstruation may be the first 
symptom of cancer of the uterus. Slight ho2Useness may be the onset of 
carcinenna of the larynx. Sarcoma of bone may give rise to pain, which 
may be treated as rheumatism for months, with no suspicion of the 
pns^ce of <?anccr* 


7^ 



790 THE NURSING OF CA.NCER GASES 

The diagnosis of cancer is not easy because it so oftoi begins in such 
a ample way, characterized only by some symptom which may be present 
in dozens of other conditions and diseases. For example many women 
think that profuse or irregulaf menstruation is to be expect(^ at the 
menopause, though it cannot be too emphatically stated that this is not so, 
and that such symptoms ought to be reported to a gynaecologist without 
any delay. 

Cancer of the rectum may be thought to be only ha^orrhoids, and the 
sufferer may go on for monffts, think&g that his trouble is one of the minor 
discomforts associated with advancing years. A little hoarseness, due fo 
cancer of the larynx, may be attributed to the onset of chronic brOnthMs 
in a man of advancing years. ;> 

Nurses should know that whereas the diagnosis of cancer may be less 
difficult when the condition is far advanced, it is to the interest of the 
sufferer that he should recognize and report any symptoms of which he Is 
suspicious as soon as he becomes aware of them. In many instances the 
condition may not be due to cancer; but, when the patient thinks or even 
fears it is, a correct diagnosis should be made, so that either the condition 
can be treated or hfe fears dispelled. No nurse should suggest that a patient 
may have cancer, she should merely advise consultation with a specialist, 
and point out that a less serious condition may easily become more serious 
unless treated early. 

Treatment of cancer. The means at the disposal of the medical pro- 
f^on in the treatment of cancer arc radium, X rays and surgery, and the 
choice will depend on the individual judgement of the surgeon in each 
case. 


RADIUM 

Radium is a radioactive substance, made up of atoms and particles 
having a hig^ velocity. The rays emitted are caUed alp^y beta and gamma 
rays, ^e latter have great power of penetration of tissue, and it is the 
gjuxuna rays which arc employed for therapeutic purposes. The rays 
emitted are similar to X rays. Radium disintegrates slowly and presents 
a constant source of radioactivity; in practice, either radium is used, or 
radon, which is a gas given off from radium. It is collected in small tubes 
or seeds; it disintegrates in the course of a few days and is useful for out- 
patient work, as the patient may be sent home, wearing radon, which 
could not be done with radium. 

The effect of radium on the tissues was first shown on workers who 
carried radium in the trouser pockets which resulted in inflammation and 
destruction of the tissues of the thigh. In therapeutic practice some 
tumours are found to be more sensitive to radium than others. The tissue 
cells are most vulnerable when they are rapidly dividing so that rapidly 
growing tumouri are more susceptible. 

origin of the tissue partlp> ukte^nes its sensibility to radium. The Skin is an 
epiffielium with a protective function which arrests fight rays and also 
arrests the rays of radium to some extent. Therefore tumours of the skin, 
tongue, amis and cervix ■vriH mact well to radium as the mys will be 
arrested hem, and so the epithelial tissue will receive the full blast of the 
application.* 

The susceptibility of tissue to radium also depends to some extent on the 



RADIUM •jgx 

iKe^eooe of oonnecdve tusue^ and on the blood wpjdy. Cancer cscU* are 
kiUed by radium and the growth of connective tirsue is stimulated; this 
rcBUlts lit the fomatioa of fibrous tissue which will contract and so, by 
pressure and stianguladon, further help to destroy the cancer cells. The 
blood-forming organs, particularly the marrow of long bones and the 
cdJs of the liver, are also very susceptible to the action of radium. 

The problem with which the radiolc^ist is faced is the provision of a 
correct dose of radium for every patient; the necessity of cutting out the 
alpha and beta rays, which are more destructive to healthy than to 
cance|rou8 tissue; and the limitation of the application of ganuna rays to 
the diseased area which he wishes to radiate. The nurse fortunately is not 
concerned with this problem, except in so far as she can help by maintain- 
ing any application in a ^ven situation and removing it at the exact time 
that has been indicated. 

The nurse, however, must be interested in the facts stated above that 
(i) the skin is more sensitive to radium than deeper structures; (2) the 
blood-forming organs are very susceptible to radium; (3) radium acts 
most effectively and easily on rapidly dividing cells, and the cells of sex 
glands divide more rapidly than any other glands in the body. 


The application of radium is carefully calculated and regulated for 
each individual case, and the gamma rays are utilized. The alpha rays are 
very irritating to the tissues, but do not travel far and can be stopped by 
very slight protection; they will not go through a piece of paper. The btta 
rays are sometimes used in the treatment of warts; for the radiation of 
tumour cases means are taken to prevent their penetrating the tissues. 
They can be stopped by a layer of platinum of a given thickness. 

The gamma rays have a selective action on tumour celb, especially when 
rapidly dividing; these will pass through several inches of lead and will 
penetrate fairly deeply into the tissues of the body. Radium is applied 
to the surface of the body on specially designed applicators; the r^ium 
is contained in platinum or gold screens. It is employed in needles of the 
same substance when interstitial radiation is employed; these needles are 
placed at regular intervals so as to obtain fairly even radiation. This form 
is used, for example, in the treatment of the tongue and breast. Silk thread 
is attached to eadi needle so that its position is known and it can be re- 
moved by pulling on this thread. 

A lai^e collection of radium is sometimes arranged as a radium unit or 
bomb. It may contain J-2 grammes or more, and is used for application 
to the suriace in order to irradiate a tumour at some distance from the 
surface. The size of the dose of radium employed has to be laige enough 
to produce a superficial reactionary inflammation. 

Radon consists of the emanations given off from radium, compressed by a 
uircial apparatus and enclosed in glass tubes known as radon seeds. By 
means patients may be treat^ with radium in their own homes 
without danger to others from the radium or danger of losing the radium. 
Radon gradually loses its potency and becomes inert in 5 or 6 days. 


A radltim reaction is accompanied by rednew, irritation and pmn. A 
few days after the application the skin begin to tingle; the uifiam- 
madoh proceeds; and the reaction reaches its manmum within tW> weeks. 
Ac this tfeae the skin is very red, covered with an exudate; it blisters and 



792 THE NURSINO OT CANCER CASES 

peels. A nurse in charge of a patient must keq> the radiologist id^smed 
of the onset and prt^;ress of the reaction. 

Tnainunt. In some cases the skin is 'weU greased with lanoUne both 
before and after the a^lication of radium, i^en the skin is broken, a 
dressing of liquid paraffin and flavine is commonly applied. Flavine is a 
useful, non>irritating antiseptic, and paraffin forms a lubricant and pre- 
vents the dressing from adhering to the skin. 

Another mode of treatment is by the application of ambrine wax, as 
described on p. 104. It is very important to have the part well dried of 
all exudate and moisture beft^re an application of ambrine is made, other- 
wise the wax will not adhere as it should. 

In addition to the local reaction described, prolonged radiation produces a 
general reaction^ with symptoms of headache and giddiness — ^in some cases 
there is loss of appetite, nausea, vomiting and diarrhoea, and many other 
symptoms suggestive of malaise occur, and various nursing and medical 
measures are undertaken for the relief of these symptoms. The anaemia 
may require to be treated, and the diet should be very nutritious. Another 
point that requires consideration is the degree of toxaemia sometimes met 
with during the administration of radiiun. 

Patients wearing radium should if possible be confined to bed, but 
in a few cases where bed is apt to be tiresome to the patient he is per- 
xnitted to sit in a chair near his bed; in this case the chair ought to be 
marked by a special label (see fig. 177, p. 524) so that everyone in 
the ward teows that the patient is undergoing treatment. 

The nurse will be concerned not so much with the actual application, 
since this is carried out by radiologists, as with maintaining the radium 
in the position in which it has been placed, and with seeing that applicators 
do not slip, and so come in contact with healthy tissue. The applicator 
miist be film, and may require to be retained in ptosition by the use of 
sandbags or bandages; and above all the patient must be coicibrtable, as 
otherwise he will not be able to keep still for long. Another very important 
point is that the patient should be warned not to touch the area that is 
being radiated, since his hand might receive injury. In cases where the 
breast is undergoing treatment it is a good plan to put a small pillow 
between the arm and the side of the patient’s body, so that the arm does 
not come into contact with the application. The radium in use should be 
checked each time the nurse attends to the patient, and at least once or 
twice a day. 

When an application of radium is made to the vagina or cervix it is 
most important to inspect the contents of bedpans for ffie presence of any 
of the gauze packing used, radium needles, or other forms of application. 

Wh(m the mouth is being treated only liquid food can be given, and 
the mouth should be irrigate both before and after feeding. If swallowing 
is difficult or painful, aspirin gargles or spraying with a weak solution 
cocaine before meals will give relief When an application is made to the 
eye a good deal of discharge occurs, and the applicator has to be removed 
at fairly frequent intervals and the eye irrigated to render it fire of dis- 
chaige. The insertion of drops of liquid paraffin will relieve discomfort. 

It is very important that nurses should realize that metallic substances 
cannot safely be used in cases undergoing treatment by radium and Xrays. 
Aperients such as calomel, which is a prqiaration of mercury, riiould be 



RADIUM 793 

avoided,* solutions of nunuury may not be used in preparing the skin of 
the patient, the hands of (^lerators, or appliances. Ointments con tainin g 
any metallic substances, such as mercury and zinc, cannot be employed 
hr treatment of the skin. Iodine also should never be used on surfaces 
whidi are to be irradiated since iodine alters the character of the reaction 
by rendering the skin more sensitive to the rays applied. 

Protection of nursing staff. Prolonged working with radium will 
cause anaemia, and this is why nurses working in the radium wards have 
their blood count estimated at regular intervals. Recreation should be 
taken, as far as possible, in the open air and a good nourishing diet should 
be provided. In the case of young nurses it is inadvisable that they should 
be in attendance on patients wearing radium for more than two or three 
raontiis at a time. But the nurse must exercise precautions and use the 
means supplied her for self-protection. She should be quick in her move- 
ments and remain near the bed as littie as possible — this need not mean 
that she will neglect the patients but that she will use her common sense. 
For example, in attendii^ a patient wearing radium on the left side, it 
would be advisable to attend to the patient from the right side of the bed. 
When obliged to handle radium, it should be taken to the bedside in the 
receptacles provided, which are leadlined. 

X-RAY TREATMENT 

As already stated, X rays are like those of radium, and X-ray treat- 
ment is employed for similar purposes. The dose is very carefully calculated, 
a minimum dose being describixl as an erythema dose, and this is the 
amount necessary to cause reddening of the skin about ten days after 
exposure. The types of treatment employed are described as superficial, in 
which the less penetrating rays are used, and deep therapy, when rays are 
employed which penetrate farther; this form is used for the treatment of 
internal organs and deep-seated glands. 

Preparation of a patient for X-ray treatment. All abdominal and 
pelvic cases, c.g. carcinoma of cervix, carcinoma of testes and ovarian 
cases, should have an aperient the night before they are to undergo treat- 
ment. Any vegetable laxatives, cascara, rhubarb, or castor oil may be 
given, but no metallic purgative may be used, such as calomel. 

Effect of X-ray treatment. The general effect on the patient may vai7 
considerably; some will have more or less marked m^aise; most cases 
complain cn listlessness, disinclination for any exertion; others suffer fiom 
nausea and may or may not be sick. Many arc sick — ^in some cases the 

E itient will vomit immediately after treatment, in other cases a few hours 
ter and some not until tiic following day. Diarrhoea may occur, and in 
cases vidiere the cervix has been treated Acre may he frequency of mic- 
turition. 

The nurse who receives a patient back to the ward, after X-ray treat- 
ment has been carried out, diould observe the patient closely for the 
symptoms mentioned and note his pulse and colour. He should be spoiled 
a li^ and given a tight meal imm^iately; if he feels sick and disinclined 
for food she should try to persuade him to have a lemon or orange drink 
containing glucose. If a patient is very sick, it may be impossible for him 



794 NURSmQ OP OANOER CASES 

to take any other form of nouzishpient for sope hours or sp. But usu^y 
the ndkness wiU abate and as soon as poadl^ a hberal imuiishing diet 
should be given. 

The general condition and a^pedte may be improved by |;iving liver 
extract In very debilitated patients half an ounce may be given mdoore 
breakfast and supper for a few days or a wedc bdordh^d. 

Local reaction. A local reaction in the form cf reddening of the, skin 
over the area exposed to X>rays may be expected in from two to three 
weeks, or may not appear for 3 or 4 weeks. In a few cases it may occur 
much earUer, even as soon as within the first 34 hours. This initial red- 
dening is temporary, and will usually .subside in a few days. 

The tr$aimmt t^plMd i 9 the skin depends on the degree of reaction; it 
may be sufficient to dust the area with powder or it may require anointing 
with lanoline. 

Special after-treatmenit necessary in certain cases, includes estimation of 
the basal metabolic rate in thyroid cases; die taking of a blood count 
after cases of leukaemia or other blood diseases have been treated; and 
washing the affected area of the head twice a day with soap and water, 
after ringworm has been treated. In this case aU hair should have lallen 
out from the irradiated area by the eighteenth day. 

General nursing care. In both radium and X-ray treatment there is 
a tendency for physicians and nurses to concentrate on a sp>ecial treatment 
the patient with cancer may be having, and to overlook the fact that he 
may be suffering marked malaise as the result of a general reaction or 
loc^ discomfort so ^at as to deprive him of sleep. In the case of women 
undergoing irradiation of the cervix and uterus they will often be antici- 
pating the next treatment with dread and fear. 

On the whole, patients suffering from cancer are cheerful persons with 
whom it is a pleasure to deal; nevertheless they have much to make them 
worried and depressed and it is the first duty of nurses to preserve a cheer- 
ful, hopeful attitude, particularly in the nursing of the untreatablc cases 
which are so difficult to handle, where in most cases it is only possible to 
alleviate symptoms and make them as comfortable as possible. 

It is advisable to supply the patients with some form of interest — in some 
hospitals occupational therapy is employed which encourages the patient 
to make an effort and so exercise both his hands and his mind, and thus 
he is prevented from brooding over his condition. 

After-care. Many hospitals have a very definite system of after-care of 
cancer cases and by this means keep in touch with each patient. It is very 
important for nurses to explain the need of this care to their patients, and 
th^ should find out what advice the physician has given and unnress upon 
the patients the value of following tlm advice. On going home tne patient 
should be told to eat well, to keep out of the sun, to avoid exposure to 
keen cold wind and not to sit near a fire, as anything which wul irritate 
a recently treated skin surface should be avpided. Patients who have had 
the mouffi treated should be advised to continue using a unqile mouffi- 
wash before and after food. 



Chapter 51 

The Nursing of the Dying and the Care of the Dead 

ike duties of doctor and nurse — The mental and physical state of a dying 
patient — Belief of distressing symptomS'^-Care of the body qfter death, last offices 

E very nurse, sooner or later, will be present at the bedside of a dying 
patient for the first time. What docs she think of death? A moment's 
reflection and she will remember that everyone must die, she will 
recollect that death is a bridge between time spent on earth and eternity. 
Death — this separation of the soul of a man from his material part or 
body — ^is dreaded by many as a terrible thing. 

As a nurse tends to the comfort and wellbeing of a patient who is ill 
during his life, so she will be prepared to help him in the important act 
of dying to the best of her ability. A patient usually knows he is dying 
though he may not wish to speak of it, particularly to his relatives. But 
he may ask the doctor or the nurse; the doctor will have to decide whether 
the patient can bear the answer. It will depend on circumstances whether 
a direct answer will be given; but the doctor, alive to his responsibilities, 
must answer — though the answer will more often be conveyed by an 
increased note of sympathy and affection in his bearing, rather than by 
words. 

When a doctor knows a patient is dying it is his duty to inform the 
relatives. The sorrowing relatives will be round the bedside of the dying 
patient; his death will leave a great blank in their lives, they will be 
obliged to reorganize their future plans without him and will attempt to 
console one another now. 

The doctor, in hospital practice, does not linger at the bedside of the 
dying; his part is easy, his visit can be made one of activity. He will now 
Older rem^ies which will help to make the last hours of the patient as 
comfortable as possible. 

The nurse, who spends many hours with her patientj will feel his dying; 
it leaves a sense of loss; she has learnt to know him intimately, she has 
been indispexxsable to his needs and has grown attached to him whilst 
ministering to them. Her presence will help to console and comfort him 
now, and it will comfort his relatives also, A dying person is very lonely 
and, unless his relatives are present, consoling and comforting him, the 
nurse should go to his side from time to time, take hold of his hand, lay a 
hand on his forehead, thus manifesting her presence by her touch. A dying 

} >erson is glad to fed the presence of someone he knows, it relieves his 
oneliness, and even though he appears to be unconscious and unperceiv- 
ing, yet, when he does open his eyes he is helped by the presence of 
another. 

Cbnvmation which the dying person is not meant to hear should not 
take place at the bedside because, even though incapable of movement, 
even of smiling, or of speech, he may be able to hear and understand 
cfistinctly. He may also be acutely conscious of discomfort even when un- 
able to give expression to his needs and will be very grateful when these 

795 



79^ the nursing of the dying 

are relieved, as, for example, by moistening his dry Ups with water, wiping 
his nose, mopping his brow and straightening the hair which may be 
faUing into his eyes; or by rcUeving his limbs of the wei^t of bedclothing 
or altering his position in bed so Aat cramp is reUeved. Distension of the 
bladder may be prevented by giving the patient a bedpan or urinal; 
he may not have realized his new but will probably use it. 

In other patients the mind wanders and memory may play tricks — ^at 
one moment the dying patient is back in the days of his childhood, holding 
imaginary conversations with persons of the past, the next moment he 
may be sensible of his immediate surroundings. The touch and the sound 
of die voice of the nurse may help to recaU his wandering mind. Whei^ a 
patient is irrational, the nurse should try to humour him — ^her presence 
at the bedside lets him see he is cared for and may quieten him. 

Dying people are apt to think of God and are grateful for the suggestion 
that a minister of religion of die denomination to which the patient 
belongs should be summoned. Aft«* the visit of the minister the nurse 
should try not to disturb the patient for fear of depriving him of his peace 
of soul. 

In deaUng with patients who arc very ill and dying, whatever the beUef 
or non-belia of the nurse may be, she must obtain fbr her patient what 
he, or his parents or guardians, would wish for him. When, for example, 
the patient belongs to a church in \riuch the sacramental system exists, 
or is practised, it is important to send for the priest or administrator of the 
sacraments as soon as possible and whilst the patient is in full possemion 
of his faculties. The priest should be informed if the patient is uncon- 
scious or unable to swallow. 

The nurse will appreciate the deep consolation brought to the heart of 
her patient by reception of sacraments which to him are channels insti- 
tuted by Christ through which His grace flows, and the essence of the 
spiritual help she can give lies in obtaining these for him without delay. 
Another more minor point she might consider would be to treat with 
r«pect any objects of piety which seem dear to the patient and to place 
these in his hands from time to time, as to him, on whose lips the words 
‘God be merciful to me, a sinner’, i^l often be found, these objects act 
as a reminder of the mercy of God. An observant nurse will notice the 
fingers of the dying trace the outline of the object under his hand, indicat- 
ing that though his lips may cease to move — ^as he becomes deprived of the 
power of speech — the desires of his heart continue to rise to God. She might 
point this out to the relatives to whom it will give great consolation. 

The following symptoms and appearance are characteristic of dying: 
The face is pale and grey, the nose pinched and cold, the eyes glazed and 
sunken with the lids half dosing over them and the ears are pale mid cold 
or blue and shrivelled. The skin is clammy and covered wim 8w:e8t. The 
pulse is weak, irr^[ular and intermittent, the breathing is deep and noisy 
and stertorous, or it may be shallow and sighing in character. In most 
patients, as death approaches, breathing is of the Qieyne-Stokes type. The 
patient may lie quietly fingering the beddothes or he may toss w arms 
about restlessly. As he gets weaker he is unable to support himself and he 
sinks very low in the 1^ as he slips from his pillows and the muscles of 
his legs relax so that they lie heavily on the bed. 

The death rattle, stertorous breathing and breathing of the Gheyne- 
Stokes type are v«y distressing fca” the relatives to hear. The rattle is due 



THE MURfllNO OF THE PYINO 797 

to mucus in the bronchial tul^s or to the trickling of saliva into the 
tradbea, or it may be due to giving the patient fluid when he cannot 
swallow. As the patient gets we^er the amount of fluid riven should be 
reduced; his mouth and lips should be moistened. As long as he can 
swi^allow he should be ^ven sips of wine and water or brandy and water 
or champagne. 

_ Salivation may be increased and the head shcaild be held over to one 
side and inclined downwards so that saliva will run out of the mouth and 
not into the trachea. Atropine is oflen ordered to limit bronchial and 
salivary secretion and so prevent the unpleasant rattle due to breathing 
through fluid. 

Stertorous breathing is due to obstruction of the respiratory passages 
by falling back of the tongue. The nurse can prevent this by keeping the 
tongue well forward, or by altering the position of the patient’s head. 
If he is lying flat the head should be held over on to one side; when the 
patient is sitting up the head should be supported and not allowed to 
roll backwards. Cheyne-Stokes’s breathing occurs in most instances, par- 
ticularly as the patient gets weaker. The administration of inhalations of 
carbon dioxide will do much to obviate this unpleasant symptom. 

The mouth of a dying patient is usually open, and this naturally causes 
the tongue to be very dry. Smearing it with vaseline or liquid paraffin 
will do a great deal to keep it soft, moist and comfortable, for as long as 
possible. It should be smeared very often — every 15 or 20 minutes — to be 
of real value. 

The nurse should have a dying patient propped up when possible as 
breathing is easier in this position; it may not be possible in a patient in 
deep coma. The head and arms should be supported and there should be 
a pillow beneath the knees in order to prevent his slipping down. 

As the circulation continues to fail the skin becomes covered with sweat; 
this should be wiped off with warm towels and the patient’s clothing 
changed when necessary. The feet get cold with a coldness hot water 
bottles and hot blankets will not warm. This coldness is progressive, and 
creeps up the body to knees, thighs and trunk. It distresses the relatives 
but the patient does not feel cold; he will complain of being hot. Death is 
very near now and it is better to remove some of the beddothes than to 
pile more on to him. But the nurse must consider the wish of the relatives, 
as they may not understand, and if they want to add more bedclothes she 
might suggest that a bedcradle should be inserted so that the patient will 
not have to bear the weight of them. 

Dying patients feel the need for air and light, and here again the 
relatives might not understand if the nurse opened wide the window. 
They would think he might be chilled, but they will be grateful if they 
are asked to do something during these last hours and, if they will gently 
fan the air on each side of the patient’s head, though not directly over hu 
face, thb will create a movement of air which will help to relieve his 
distress. Towards the end the sphincters relax and urine, and possibly 
faeces, may be involuntarily pabed. The provision of pads of tow and 
wool, which can be changed fi^ucntly, prevent soiling of the bed 
and keep it fme from unpleasant odours. 

The faculties are rsqiidly fliiling and the patient feels very lonely. He 
can now hear only what is srid directly into his car; he clings to the 
toudh of those about him, lapses into a state of semiconsciousness, but 



7^ ties NtriaiMo of thf dyino 

from time to time will peHia{}i open his eyes and be content to see those 
he loves aroOnd him. He knotvs he is dying and he puts the hand of one 
fnend into that of another, mutely saying'^'be good to my xnother’, or, 
‘lo^ aRw ^ child’ as the Founder of Christianity wud when He was 
dying. His lips may be moving as he utters the name of a loved one or in 
prayer. 

As the relatives, the nurse and perhaps the doctor, if he is a &mily 
friend, stand around the bed it can truly be said — ‘they also serve who only 
stai^ and wait’. Even if silent, their ^cnce is<active as the silence of the 
millions who keep the two minutes' silence at the cenotaphs of the world 
on November i ith. They are helping their dying one as best they Imow 
how. 


Pray for me, O my friends; a visitant 
Is knocking his dire summons at my door. 

The like of whom, to scare me and to daunt, 

Has never, never come to me before; 

'Tis death — loving friends, your prayers! — ’tis he! ... 

As though my very being had given way. 

As though I was no more a substance now. 

And could fall back on nought to be my stay, 

(Help, loving Lord! Thou my sole Refuge, Thou,) 

***** 

So pray for me, my friends, who have not strength to pray. 

Dream of Germtms. 

If the patient is conscious and is opening his eyes from time to time 
the shade should be removed from the light and the curtains drawn 
back from the window. The dying person will try to face the light, as 
for him darkness is falling rapidly and, like a child, he fears the dark. 

At the end, death is often very easy — ^it is like falling asleep. Many peiv 
sons are quite oblivious of dying. Any convulsive movements which occur 
do not distress the patient and the nurse should tell the relatives — for 
their consolation — that he docs not feel them. He has ceased to fed and 
is at peace. To some extent this accounts for the peaceful expression so 
often seen on the face of the dying and the recently dead. It is often a 
great consolation to the relatives and helps them to realize that for him 
fife’s stru^le is over and reminds them that they can have confidence in 
his happiness. 

As soon as the patient has breadied his last the nurse should gently 
close his eyes, if they are not already closed. She should then lead the 
relatives irom the room and in hcepital should bring sister or the doctoi^ 
to speak with them. She then returns to the sickrooom in order to attend 
to the body. If possible she should have help as the body can be more 
easily and more reverently handled by two, as it is now a dead weight 
to move. 

The bedclothing should be removed and one sheet left covming rite 
body. All pillows, bedsters, air ring or Water pillows should be taken 
out of the bed and if a large water b^ has been used it shotdd be aattptiod. 

The body should be placed flat on the bed with the len quite 8tim|[ht, 
and to prevent their fiming apart they may be ti«i toge^ter with a piece 
of bandage or kept in position by means <m sandt»^; Ae feet should be 


Ntmtmo O# TltE CYtNO 7^ 

itopjpOTted by a aihdbag to prevent footdrop. The hands and arms should 
be arranged according to the custom of the hospital— in many cases 
stiaight ^wn by the sides of t^ body, Unless the relatives wish them to 

1 breast. In jmvate practice the relatives should be con- 

sulted on this point. Some means should be taken to prevent the jaw from 
drtgiping— it may be secured by means of a four-tailed jaw bandage or 
kept in pmition by placing a small pillow beneath the chin — one could 
be improvised by wrapping a wad of brown wool in a towel. Jewellery 
is usually removed from the body in hospital, but when private nursing 
the muse must consult the relatives. 

TTie bottom sheet should be drawn tight and the bed made quite tidy. 
The body is allowed to lie for an hour before the last offices are per- 
formed. 

XAST OFFICES 

The laying out of the dead should be reverently and quietly performed; 
all unnecessary talking must be avmded. The articles needed for this in- 
clude: Warm water, soap and flannels, and towels to wash and dry the 
body; a hairbrush and comb, nailbrush and nail scissors. Moist swabs 
should be provided to cleanse the orifices and wool and forceps if they are 
to be plugged; fine forceps and small pieces of wool for nose and ears, 
larger forceps and a wad of white wool for the rectum and brown wool 
for the lower part of it. White wool is absorbent and will collect fluid, the 
brown wool being non-absorbent will prevent the fluid from running 
out. In some gynaecological cases the vagina should be packed tightly 
with gauze. If there is a wound, a clean dry surgical dressing should be 
supplied. In the case of a discharging wound, gauze packing should be 
inserted and a carbolic compress us^ to cover the wound, and wool, 
binder and needle and cotton to secure the dressing in position. 

Either clean personal clothing should be provided or whatever dress 
the relatives wish used for the dead body. In hospital a shroud with 
safety pins to fasten it and a label to attach to the body are usually 
employed. 

If tlK body is verminous it will be necessary to supply a small tooth 
comb for the hair and swabs to pick the lice off the body; every particle 
must be removed as lice walk off the dead and will crawl on to other 
people, and this point must therefore be most carefully attended to. 

Whenever possible two nurses should be supplied for the laying out of 
the dead; it is difficult for one to move the b^y and with two the office 
can therrfore be more rapidly and more quietly and reverently carried out. 
The amount of washing necessary depends on the condition of the body, 
but it should be sponged and dned in all instances in order to remove 
moisture, though it need only be thoroughly soaped if the body is dirty. 
If the nails require to be cut this should be done quietly, particularly if 
the work is being done behind screens in the general ward of a hospital — 
the other patients know that the patient has died and they are following 
the movements of the nurses behind the screens however much they may be 
trying not to take any notice of them; therefore the more noiseless the 
work the less distress is given to others. 

The hair should be brushed and combed and arranged as the patient 
liked it during his life, as this will be most pleasing to the relatives; the 
features should be set to look natural and the lips for example plac^ to 



800 THE NURStNO 07 THE HYtNO 

look as if the mouth has just dosed and not be set and hard. Ihe face 
should look as if in peace^ sleep. It is usual to get a barber to dhave t^e 
face of a man, so that it looks fimhly groomed. 

The shroud supplied in homital is easy to adjust, the body is then 
tightly fastened up, mummy i^hion, in a mortuary sheet stitched, not 
pinned, a label on which is written the name c£ the patient, the time 
of his death and the name of the ward is stitched on the front cd'it. In addi- 
tion, in some hospitals, a label bearing the name d* the patient is &stened 
round his ankle. These precautions are taken so that the undertaker shall 
not make a mistake when he comes to make funeral arrangements. 

In a private house the nurse should arrange the patient lying on a 
dean white sheet, wearing the clothing provided, and cover die body 
with a sheet and perhaps a white quilt — turning the sheet over so as to 
give the impression that the patient is lying in bed. The head should be 
arranged on a fairly low pillow and the face covered with a linen or lace 
veil; this can be removed when the rdativcs are in the room but it prevents 
flies from setding on the face when no one is in attendance. 

The nurse should inquire whether there is any object of piety the 
relatives would wish to be arranged in or about the hands of the dead 
person — they may prefer to attend to this point themsdves, but will be 
grateful for the consideration of their feelings shown by this request. 

Everything used for the last offices should be removed from the room 
as quickly as possible and the nurse should take pains to make the room 
neat, and, pleasant to look upon. She should inquire whether the relatives 
would care for her to arrange flowers in it and, as she will remain in the 
house until after the funeral, she should be at hand to take in flowers as 
they come, and place them in the room or help to do so, but she must ask 
where the relatives would like them put and suggest that perhaps they 
would like to move them. If she shows that she realizes that those sent 
by the nearest and dearest ones would be liked nearest the bed or on the 
b^ the relatives will be grateful for her imderstanding sympathy. 

In the case of Hebrew patients who die, every nurse should know that 
the Jews do not like their dead handled by Christians and she must respect 
this. In some hospitals special Hebrew watchers are appointed; in others 
they are available and can be obtained as required. The nurse should be 
careful to ask the relatives what their wishes are; she may in smne cases 
be asked to perform the last oflices for them, in others she may be asked 
to help; but, in all cases, she should not touch the body after death without 
first ascertaining the vmhes of the relatives or of those responsible. 



Appendix i 

The Principal War Gases and their First-Aid 

Treatment 

BLISTER GASES 
LUNG IRRITANTS 
NOSE IRRITANTS 
TEAR GASES 
ARSINE 



Ndm and Gnmp 


Principal War Gases an( 


PfOPerHet 



Pifsisimey 


Blister Gases: 
Mustard gas 


1 An oily liquid which may vary Very persistent. ; Smell of garUo, onions, 

I in colour from dark brown to radish or mustard. Liquid 

straw yeQow. Sohibia h) oU i maybaieek. 

and spirits. Neutralised by 
bleaching powder {chloride of 
lime). Great power of pane* 
traticm. Has high freeein| 
and boiling points. liquid 
when evaporating, gives ofi 
invisible gas. 


Lewisite A colourless liquid In the pure Persistent. Smell of geraniums, 

slate, but when crude is dark 
bioan; gives off an invisible 
gas. Is rapidly destroyed by , 

water and any alkali. Pene- 
trates materiaas. Has a very 
low freezing point. 


Lung Irritants : 

Phosgene 


A gas -almost invisible. Cor- Not pwsistent. Smell of musty hay, 
rodcs metals. Is rendered less 
effective by heavy rain. 


Chlorine 


Nose Irritants : 

D.M. 

(Di-phenyl-amine- 

chlorarsine) IS 


r 

I 

D.A. g 

(Di-phenyl-chlorarsine) < 


A gas— greenish colour. Cor- Not persistent, 
rodes metals. Is dissolved in 
water. Will eventually rot 

clothing. 

A ydiow crystalime solid which Not persistent , 
when heated gives off an al* 
most odourless smoke. Gener- 
ally invisible except near the 
source. Can still be effective 
althouidi uot visible. 


, White solid. ! Not persistent. 


D.C. 

(Di-phenyl-cyaao-arsine) 

Tear Gases: 

CAP. 

(Chlor-aoeto-phenone) 


I j Ditto. Not persistent. 

i A solid. Gaseous state s^ost j persistent 
kvi^bie. 


SnuOl like bleaching powder 
(Chloride of lime). 


Buiiing thK«t and 

mouth. 


Ditto. 

Ditto. 

iStatkmTo eyes kdliwev 


K.S.K. 

(Ethyl-iodo-acetate) 

B.B.C. 

(Bronm-benayl-cj^de) 

Airsine: 

(Calcium arsenide powder) 


A dark brown liquid. Gaseous 
state invisible. 


Persists for somej Smellof pear drops, 
hours. 


Brown liquid. Gaseous state! Persists for days. 

tovisibla . 

tlves off arsine (a wlutis^ I Not persistent 

der), when motstened. 


Pungent odour. 

1 CftiSnuit to detect 



thdr Fiist-^Aid Treatment* 


(i) Litmid i 

(а) £}^.-~InmMdiately irritant . Irritation may pass o0 
temponcUy Imt nlnnia. Byai cloaad and man out 
of action m about an hour. 

(б) irritation on contamination. Redness 

oommences in about a bourn and progresses to 
•weUing and bllstermg. SUstera appear in from 
i3ioa4hottCf. I 

(M) Vaponrt i 

(«) Jtyai.-— No irritation during eapoetire ezc^t tears ) 
if concentration high. Later inttation with in- i 
flammation and swiping possibly causing tern* ; 
porary blindness in 04 hours. 

(6) Lungt . — ^No irritation at time of exposure but garlic- | 
like odour may be detectecL Later, loss of voice 
and cough. In 14 hours ct longer Bronchitis and ' 
Broncho-Pneumonia with possibly fatal results, ! 
{c) Skin.^Ho irritation on exposure, ^me hours later j 
redness perhaps developing into swelling and even , 
Mistering in 24 hours or longer. In an unprotected 
case the eyes are most likely to be damagM and the | 
skin the feast likely. 1 

(<f) Stomach and Intestines . — WUl be severely injured by * 
swallowing frxxl contaminated by mustard gas. 


(<») Effect immediate. Injury permanent. 

[b) SaiH.— Stinging may be felt vduun a minute. Red- 
ness shows quickly and blisters will appear in a 
Shorter time than from mustard gas. 

(ll)Vttpoiir« 

Detected by smell of geraniums and severe irritation of 
nose which will compel the vreating of a respirator or 
withdrawal from the atmosphere. On skin is much 
less effective than mustard vapour. 

Delayed effects, but less so than mustard gas. One to 
three hours. 

^hly lethal, duo to damage to lunjM, 

Early. “-Cough. Watering of eyes. Tightness and pain in 
chest. 

Lofer.-— Oedema of lungs. 

Effects appear from 0 to 24 hours. There may be a period 
of apparent Veil being* after early syiuptoms. 

Wtto. but no period of apparent Veil being’ 

Not so deadly as Phosgene but more irritant. 

Effects appear from 0 to 24 hours. 


PirtP^id Tfeatmeni 


Time is a vital factor. 

R^irator protects eyes and lungs. 

(i) Liquid in eye {probably pemaneni injury) : 

(a) Irrigate eye immediately with warm water and con- 

tinue for 10 minutes. 

(b) After irrigation instil a drop of liquid (medicinal) 

paraffin, or smear lids wlm vas^ne to prevent 
them sticking together. 

(r) Do not bandage eyes. Eyeshade permissible. 

(E) Liquid amUmination: 

(a) Protective ointment (2 parts'j For effectiveness ap- 

of bleach to i of vaseline). I ply within 5 min- 

(b) Bleach cream (equal parts of f utes. Rub in for 

bleach and water). J x minute. 

Ic) Soap and water. 

(dj Solvents such as petrol, or paraffin. 

US Remove clothing at earliest possible moment. 
if) Wash body with soap and water. 

(iii) Vapour eoniaminaiion: 
ia) Remove clotl:^. 

(b) Scrub body with soap and water till skin turns pink. 
Note . — The best treatment is that which is most readily 
available. 

Blisters . — ^Do not burst, cover with light dressing. 


; (i) Liquid in eye: 

i As for mustard gas , but action must be immediate if 

it is hoped evejj to mitigate the injury. 

(ii) Liouid eontaminaiion: 

Wash with soap and water, or alkaline solution. 
Remove clothing at once. 

Wash with soap and water. 

I iVoftf.— Lewisite contains arsenic, so blisters when formed 
should be evacuated aseptically to prevent further 
absorption of arsenic into the body from the blister fluid 
^ which contains it. 


Respirator protects, keep on till out of gassed area. Remove 

I contaminated clothing. 

Reri.— Most important. Fatient should bo a stretcher case. 
WafWfk.—To prevent shock and shivering. 

Ojtygm.— When breathing becomes etnuarrassed from 
o^ema of lungs. 

No alcoholic stimulants. Hot sweet tea may be given. No 
smoking. 

No artificial respiration, except as a last resort. Cause 
damage to lungs. 


Bi^ng pain in nose, mouth and throat. Pain in gums. 
Sneexing and coughing. Pain and watering of eyes. Run- 
ning from nose and mouth. Headadto and pain in chest. 
NausM and perhaps vomiting. Symptoms may increase in 
imeaany for a time after removal to pure air, but willpass 
off. Acute mental denression. 

Ef^ts may be driayed for a law mimites after exposure. 

Symptoms tend to get worse. 

Non-Iethal. 

Ditto.' 


Ditto. 


Cojpiom^ flow oif tcari mul spam of eyelids, ^ight skin 
irritation. 

I tnmw i fl a t e effects, vriiich cease on removal from the gas or 
on adjustment of respirator. 

As for C.A.i*. No sl^ irritation. Liqtdd in eye dax^jieroos. 


Ditto. 


Respirator protects. 

S>'mptoms subside after initial tendency to increase, on 
removal to pure air. 

Rest. 

^ Fresh air. 

Remove contaminated clothing. 

Alcoholic stimulant can be given. Wash mouth with hicar- 
bonacte of soda solution, 
j Watch for severe mental depression. 


Respirator protects. 

If irritation persists wash out eyes with warm water or 
normal saline. 

If skin irritation persists, wash with soap and water and/or 
apply vaseline. 

j Remove contaminated clothing. 


Gastric Aiscewtet. nanseai vtS^ting and giddiness. Cold- [Respirator protects.^ 
nes* abd ^viriflC. Pulse rate slosfa* Unne diminished, IKteep patient still. Give glucose drinks. Fluids by mtra- 
haematnna. Jaundice occurs later. j venous route may be necessary. 


^ For ftilfiff fofeViiMitfoai ddr Raid Precaution handbooki, Noi« a & 3, are recommendid. 



A^penMx 

Table of Vitamins, Giving the Name, Source, 

Requirements 

NAME j SOURCE ! DEFICIENCY DISEASES 


A Fit Sidnble (Anti-xeroph* 
tbalmic or inti-iiuecUve vita- 
mio). 

i» pro-vitamiii A which 
is coovertra into vitamin A in 
tba body. 


1 FiMiUvBroiI»(^**"‘ 

Kuk. 

Batter. 

Vitaxniniied margarine. 

Carrots. 

Green vefetabies. 
j Pteparatioas of vitamin A 
, (ooncentrated). 


Nighi, BHndnw* ^ ^ 

XeritiB, a condition of the 
mucous membranes which pre'* 
disposes them to local imec- 
ttons. 

Xam^Cftofmlcu 


D A Fat aotiibla (Anti-raehitic < fhalihnt. 

vitamin). 1 Fish liver oUs< cod. Tooth caries. 

Promotes absorption of calcium ' i tunny. i Osteomalacia in adults, 

and phosphate and therefore : Henin^ 
promotes bone calcification. Egg yolk. 

By giving in excess hyper-vitamin- i Bnttm. I 

oj^ may be caused. Synthetic vitamin (catcifeiol 

I prepared by irradiation of 
erfoaterol). 

lira&ition of the body bv son- 
light, natural or artificial, 
hmpa the formation of vita- 
min 0 in the akin. 


G Water aolnble (Anti-scorbu- | Fresh fmita. 
tic vitamin). | Orange and JLemon Juice. 

I Blackcurrants, 
i Tomato juice. 

> Potatoes. 

I Cabbage, 
i SpinacA. 

; Salada. 

Rose hip tymp. 

' Ascorbic aod. 


ScssBS^ (i) the infant becomes 
restless and sallow, and is liable 
to brtmcbial and skin infec* 
tiofis. (a) If the ccmdition la 
allowed to continue. Barlow’s 
disease or 'scurvy rickets' de- 
velops with the typical symp- 
toms described on p. apz. 


B, TMamitt. Water aotable. 
also known as vitamhi F 

(anti-beri-beri or anti-neuritic 
vitamin). 


; Wheat germ. 

Wboleimml bread. 

Brewer's yaast. 

! gayoik. 

Peas. 

Oatmeal. 

! FroiU. 

! Vegitablei. 

I Synthetic pceparaiioD—oneiirin. 


BeH»heH (a form of polyneuri- 
tis) which occurs hi the East 
where polished rice is the prin- 
cipal food taken by the natives. 

Folyneorfite doe to toxic con- 
ditions. 


B, (complex) Same foods as Bi and 

Water aonsbie, alao called G. in Cheese. 

America liver. 

(«) (P.P. factor or the pellagra- Heat, 

preventing factor; niootlnic 
acid). 

(fi) (Ribcdlavin or laotoflavin). 

K Fmt CkMMa Wheat. 

Gieea leavea such as lettuce. 


PBUtfgrB which occurs chidly in 
couDtriet such as the Soathm 
States of U.S.A. where the 
natives eat principally maite. 

Slomniffla particularly at the 
angles of the mouth. 


By experiments on animals it is 
found that vitamin E promotes 
fertility. It is thought t^t 
vitamin B may prevent abortion 
in wome^ and a diet rich in 
vitamin E is recommended for 
expectant mothers. Synthetic 
preparatioiia of it axe given td 
women with a tendmy to 
abortioo. 


K Fat BoteAda, (anti-baemor- I Green leaves. in 

rhagic or 'Koagnlation vita- PigVUver. wmcn haemmxliagic disease is 

m^). ! likely to oocur in infants, and 

hleedinf in post-operative ob- 
structive jaundice because the 
blood loses the power of dolthlif , 
and dotting tima is prolonged. 


F Water soiable 


Lemon )afoe. 


{ QvaMrF#N>«V 



Diseases Produced by Deficiency and Daily 


When Known 

l>AaY REOmREMENTS IN INTER- 
NATIONAL UNITS 


Adults a,ooo to 4,000 1.U, 
Childron 6,000 to 8,000 LU. 


DIET PROVIDING 

DAH-Y REQUIREMENTS 

Ordinary diet provided one pint of milk daily and 
a reasonable supply of butter or vitaminized 
margarine and good allowance of green vege- 
tables are given. 


Adults 500 I.U. 

Children 500 to 3,000 I.U. 


Children do not receive sufficient vitamin D in 
their diet and therefore always require hsh liver 
oils or synthetic vitamin D added to the diet. 


Adults 500 to x,ooo I.U. j 

Childiiea 1,000 I.U. obtainable as ascorbic acid in. 

tablets of 35 and 50 milligrammes. 

Babies require 200 to 400 I.U. 

Vitamin Cis of great importance in raising the resis- 
tance in acute infections and in promoting the 
healing of wounds. 


Adults 500 I.U. 
Children 400 I.U. 


A diet containing a reasonable amount of green 
vegetable with the juice of an orange or lemon 
a day is adequate. In war-time either the specially 
pxepm^d black currant pur6e or rose hip syrup, 
or ascorbic acid 25 to 50 mm. daily s&>uld & 
added to the diet. Vitamin C should always be 
added to gastric diets and to the diet in most 
institutions, including hospitals. 


A good mixed diet containing wholemeal bread 
in place of white bread. 


No intematioiial standard. 


As and containing cheese in addition. 


No Internatiocal standard. 


No international standard. A mixed diet • 

OmmmL Before operation for the relief of ob- 
structive jaundice the pro-thrombin level of the 
blood is determined and if dehciency is shown 
smne preparation such as *Synkavjt^ (a Roche 
piodBct) is given for several days either by mouth 
or injscticm. 


No InUmtional standard* 


1 



Appendix III 

Questions Set in the Final State Examinations 
May 1939 to April 1944 


May 1939 

MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed 1} hours 

Compulsory, Describe the course of a case of Scarlet Fever. How would you 
nurse this in a private house? Mention the complications which 
might arise. 

Compulsory. 2. Mention the possible causes of Mclaena imd describe the treatment 
of a case. 

3. How would you treat Chorea in a child of seven years? 

4. To what symptoms may Uraemia give rise? How is uraemic 
coma treated. 


SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMEOT 

Time allowed hours 

Compulsory, i . Discuss the after-treatment of a patient with Chronic Bronchitis, 
who has been operated on for a Strangulated Hernia. Indicate 
what complications might reasonably be anticipated. 

^Compulsory. 2. Of what symptoms may a patient with Uterine I^Iapse complain? 
Discuss what forms of treatment might be adopted. 

3. Describe the preparation of a patient who is to be given a local 
anaesthetic. V^t instruments and anaesthetic solution would you 
make ready, and how would the instruments be sterilized? 

4. What steps would you take in an emergency to check bleeding in 
the following circumstances: 

(a) Cut on the scalp; 

(b) After operation for haemorrhoids; 

(c) Infected amputation stump; 

(</) Growth of ^e tongue; 

(e) Along the track erf* a drainage opening in the abdomen; 

(/) Ruptured varicose vein? 

(Five only need be answered.) 

GENERAL NURSING 
Turn allowed 2| hours 

Compulsmy. 1. Describe ntirsiiig treatment oS a patient suffering from acute 
lobar pneumonia; zmsntion uny complications which may arise. 

Compulsory- 2. Describe one method which might be employed in the preparation 
of sldn, for a patient to have an open operatim On his ki^ 

806 



QimrnoNs 807 

Cmpulsofy. 3. What would be your nursing care during the first night in hospital 
of a patient suffering from Exophthalmic Goitre? 

4* Name three countenrritants^ state the purpose for which each is 
used, and describe the meAod of application of one of these. 

5. What emergency treatment wotild you give for the following: 

(a^ A bee sting; 

(i) Crushed fingers; 

(r) Fainting attack; 

(d) Scald of foot? 

6. How would you feed a baby ot three months with a harelip before 
and after the operation for its repair? 


November 1939 

MEDICINE AND MEDICAL NURSING TREATMENT 
Tim allowed 1 hour 

Comptdsoiy* i. To what causes may jaundice be due? How is simple catarrhal 
jaundice treated? 

2. What symptoms may arise from a deficiency of Vitamins B, C or D 
in an adult^s diet? 

3. What are the signs and symptoms of scabies? How is it treated? 

SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TOEATMENT 

Tim allomd i hour. 

Compulsory, i. Discuss the principles underlying the various ways in which a frac- 
tured limb can be immobilized. Give suitable examples to illustrate 
the advantages of methods described. 

2. What diseases commonly affect the oesophagus? How may they be 
recognized? 

3. A has had a corrosive fluid poured all over her back. Discuss 

the nursing treatment of such a case. 


GENERAL NURSING 
Tim allowed 2 hours 

Con^mlsory. i. Under what conditions are bedsores liable to form? Explain in 
detail the means you would adopt to prevent their formation. In 
the event of a bedsore forming, what treatment would be carried 
out? 

Compulsory. 2. How would you distinguMi between haemorrhage from an artery, 
a vein and a capillary? What immediate action would you take to 
arrest the bleedimg in each case? 

3. How is the infection of typhoid fever transmitted? State the pre- 
cautions a nurse would t^e to prevent the spread of infection. 

4* What may a nutie do for her patients to relieve the following con- 
ditions: 

{a} Hiccough; 

Difficulty in nuct^ 

(r) Post^'^aimesthetic vomiting? 

Desmbe m treatment of a patient suffering from a 
chrcmic discharge from the ear. 



API>£HDIX 


do8 

Apiul 1940 

MEDICINE ANt> MEDICAL NURSING TREATMENT 
Ttam allowed 1 hour 

Comfmlsoty, t. What arc the sigm and symptoois of Acute Nephritis? What would 
be the treatment <£ a case in a child of ten years? 

2. To what symptoms may a pleural efiusion give rise and how may 
the condition be treated? 

3* What are the symptoms of an overdose of: 

{a) Thyroid gland tablets; 

(b) Digitalis; 

(c) Stryclminc; 

(d) Morphine? 


SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Tim allows i hour 

Compulsmy. i. In what ways can an Ovarian Cyst cause inconvenience and even 
endanger me? Discuss the nursing treatment after operation for the 
remov^ of an adherent cyst. 

2. In the absence of full hospital equipment, what extemporary 
measures would you take to treat a patient suffering from severe 
surgical shock? 

3. Discuss briefly the treatment and the possible complications of the 
fcdlowing: 

(a) A flsh*hook embedded in the finger; 

{b) An open safety«pm impacted in the oesophagus; 

(r) A marble or pea lodged in the nose; 

\d) A violent blow on the eye»ball. 


GENERAL NURSING 
Tim allowed 2 hours 

Cotnfndsoty. 1. Describe the post-opemtive care of a patient for the first fiorty* 
eight hours afi^ Tonsiilectomy. 

Con^ndsofy. 2. Ebw would you nurse an old man suffering from Bronchiectasis? 

What st^ would you take to {prevent the offensive odour of the 
sputum mm disturbing him and other patients? 

3. How would you prepare the following: 

(a) Albumin water; 

(b) Barley water; 

WEggffip? 

Mention the cooditiotia for wbidi each may be preacribed. 

4. Mention aome of the camei of inioninia. What ttqa may be taken 
(apart from the administration of drugs) to relieve the conditkn? 

5. Describe exactly how you would proem to |;ive an antrum wadi* 
out after an (qieration £or draining the maxillary antrum. 

Oetobn during existing war emtrgemy tondSUmtt. 



QVEStlONS 


809 


OcrroBER 1940 

MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed 1 hour 

Compulsory, i . Describe the symptoms of heart-failure arising in an old-standing 
case of Mitral Stenosis. 

2. A patient in your ward suffering from a gastric ulcer a large 
haematemesis. What would you do? 

3, Describe an acute attack of asthma and say what can be done to 
give the patient relief* 


SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Time allowed 1 hour 

Compulsory, i. What arc the possible complications of urethral catheterization? 
Discuss the merits of different types of catheters. 

2. What is Erysipelas? Discuss the nursing of a case and indicate the 
treatment that might be adopted. 

3. What is the significance of posture in nursing a patient in bed? 
Give examples to illustrate the advantages of different positions. 


GENERAL NURSING 
Time allowed 2 hours 


Compulsory, i. 
Compulsory. 2. 

3 - 

4 - 

5 - 


For what purposes may tepid sponging be ordered? Give in detail 
the method of procedure. 

Give the preparation for operation and the post-operative nursing 
treatment of a patient who has had complete excision of breast. 
What methods of disinfection are used in nursing? Give a brief des- 
cription of these, explaining for what purpose each method is most 
suitable. 

Describe any one nursing method used in the treatment of: 

(a) Varicose ulcer of the leg; 

{b) A bedsore. 

Describe in full the procedure of strapping a chest for fractured 
ribs. 


April 1941 

SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Time allowed 1 hour 

Qmipulsory. i. Discuss the nursing treatment of a patient who has sustained a 
penetrating wound of tl^ scalp and hm become unconscious. What 
complications might arise? 

2« Dts(^ in general the causes ofintestinal Colic. Describe the synq^* 
tcans and state what observations you would make if the condition 
persists* 



8io 


APPBHDIX 

3. What is meant by Haematuria and what are its common causes? 
Discuss the nursing treatment of a case in which any one of these 
causes has given rise to severe Haematuria* 


GENERAL NURSING 


Time dlawed 2 hours 


Compidsofy. i* 
Compukory, 2. 

3 - 

4 - 


Describe the nursing of a patient suffering from acute Rheumatic 
Endocarditis. 

Name some of the complications to be feared in the case of com- 
pound fractures contaminated by soil. What warning symptoms 
might herald the onset of such complications? 

A patient is to have a Mastoid Operation. Describe in detail the 
loc^ preparation necessary. 

What would you do in the following emergencies pending the 
arrival of the Doctor: 


(<z) A case of Carbon Monoxide (Coal Gas) poisoning; 

(6) A person whose clothing has caught fire; 

(f) Sunstroke? 

5. What arc the early sigm of Pulmonary Tuberculosis? How would 
you nurse a patient suffering from this disease in a general ward^ 
pending his tranrierence to a Sanatorium? 


MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed i hour 

Compukory. i. What are the symptoms of Anterior Poliomyelitis and how is it 
treated during the first week of illness? 

2. What observations would you make of a case oS persistent vomit- 
ing? 

3. What symptoms may result from Pernicious Anaemia? How is the 
condition treated? 

September 1941 

MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed i hour 

Compulsory. 1. A diabetic patient has taken a large overdose of insulin; what 
symptoms may result, and what treatment may be used for such 
a case? 

2. What are the symptoms of Exophthalmic Goitre and what is its 
medical treatment? 

3. What are the symptoms of acute cerebro-spinal meningitis? How 
might such a case dc treated? 

SURGERY AND GYNAECOLCXSY, and SURGICAL and 
GYNAEGOLCXJICAL NURSING TREATMENT 

Thu attowed i hour 

Conpulsory. u What eonditi0ns smy ariieas the remlt of apeiiet^^ 

the «heit? Indicate what symptoms might ocoar^ and what lines 
nursing treatm<mt would take* 



Q:I7S8T10N8 8ll 

a. I&cufls briefly the methods by which bleeding can be arrested and 

f ive examples. 

or what reasons is the operation of Gastrectomy performed? Dis- 
cuss in detail the post-operative nursing treatment. 


GENERAL NURSING 
Tim allowed 2 hours 

1. What arc the causes of Convulsions in children? Describe the 
nursing treatment* 

2* Give a detailed account of the nursing of a patient who has under- 
gone M operation for Gall Stones. 

3. A patient is admitted to hospital suffering from severe headache. 
What nursing measures could you employ for his relief? What ob- 
servations would you make before reporting about this patient? 

4. How would you modify a normal ^et in the case of a patient 
suffering from: 

(a) Acute Nephritis, 

(b) Chronic Constipation? 

5. What do you understand by the following terms: 

(a) Blepharitis, 

(b) Glaucoma, 

(c) Conjimctivitis? 

Describe the treatment and nursing of a patient suffering from one 
of these conditions. 

April 1942 

SURGERY AND GYNAECOLOGY, and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Tim allowed i hour 

Compulsory* i. Discuss the preparation of a patient for the operation of gastro- 
enterostomy, and the post-operation nursing treatment. 

2. Discuss the signs and spnptoms of exophthalmic goitre, and dis- 
cuss the preparation of a patient before the operation of partial 
thyroidectomy. 

3. What do you understand by: 

(aj Simple new growth; 

{b) Malignant new growth? 

Give examples of each, and describe how they differ one from the 
other in their behaviour. 


MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed 1 hour 

Qmpubory^ 1* To what may Cerebral Haemorrhage be due? What are the iignt 
and sytnptoms oi this condition and what medical treatment may 
beordar^ 

a* What dang^us oondititms may arise in the course of Lobar Pneu- 
monia? ^^at would you regard as danger-signals in this disease? 


Compulsoiy* 

Compukoiy* 



8i 2 APFlftNt>« 

3* What do you understaiKl by the teniis: 

(a) CiiTbosis of the liver; 

(b) Heart*bIock; 

(cr) Leucocytosis; 

(d) Orthopnoea; 

(tf) Embolism? 


GENERAL NURSING 
Tim allowed 2 howts 

Compulsoiy. i . In what conditions is acute delirium most likely to occur and what 
forms may it take? Describe the nursing of a delirious f^tient* 
Compulsory, a. What is meant by the term "thrombom? In what surgical con- 
ditions may thrombosis of the veins of the leg occur, and how would 
you recognize it? What special nursing care may the patient re- 
quire? 

3. For what ptirposes are the following used, and how arc they ad- 
ministered: 

(a) Insulin; 

(b) Antiphlogistine or Kaolin poultice; 

(c) Dover’s Powder; 

(d) Menthol; 

(e) Ox Bile? 

4. In what ways may oxygen be administered? Describe in detail any 
one of these methods. 

5. A patient is to have a blood transfusion. What preparations will 
you make with regard to: 

{a) Your patient; 

(b) The requisites for the transfusion? 


Septembxr 1942 

MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed 1 hour 

Compulsory^ i* What conditions may give rise to incontinence of urine in an adult? 
Outline the treatment for a case of one of these. 

2. Describe the symptoms of Bronchial Asthma. What treatment may 
be given to relieve an acute attack? 

3. Give the cause, signs and symptoms of Scabies and one method of 
treatment for this condition. 


SURGERY AND GYNAECOLOGY and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Time allowed 1 hour 

Compulsory. i» Describe the treatment of a case of ihuttire of the 

dorsal region. What may be the comfdk^imis of such an injury? 
2. For what exmditions may abdcmunal hy^etecicmy be per^^ 
Discuss how you would prepare a patimt tor thh operation, and 
how )mi woiud nunie her afterwai^ 



Q^UESTiam 813 

3« Discim one form of treatment dfa severe bum of (a) the abdomen 
and (A) the forearm arui band. 


GENERAL NURSING 
Time allowed 2 haws 


Cmpfdswy. x. 


Compulsofy. 2. 


3 - 


4 - 


5 * 


For what reason is the operation of perineorrhaphy performed? 
Describe in detail the nursing of a patient before and following the 
operation. 

State the signs and symptoms of acute nephritis. Describe fully the 
nursing treatment of an adult patient suffering from the disease. 
What are the symptoms of faucial diphtheria? Give an account of 
the nursing of a patient suffering from the disease. 

Name three drugs prescribed to induce sleep in a restless patient 
and state the usual adult dose of each. What purely nursing 
measures would you supplement to aid in producing the desired 
effect of the drug? 

For what mediceJ and nursing purposes may the following be em- 
ployed: 

(a) Hypertonic saline. 

{b) Barium sulphate. 

(r) Turpentine? 

State briefly how you would prepare and administer any one of 
these. 


April 1943 


MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed i hour 


Compulsory. 


1. Describe a case of Acute Rheumatic Fever in a young adult. How 
may this be treated and for what complications would you watch? 

2. What are the complications of Diabetes Mcllitus? Describe briefly 
how they may be treated. 

3. For what conditions may the following drugs be used? How and 
in what dosage are they given? 

{a) Paraldehyde; 

(b) Ephedrine; 

(r) Amyl Nitrite; 

(d) Hyoscine; 

(e) Hexaminc (Urotropine). 


SURGERY AND GYNAECOLOGY and SURGICAL and 
GYNAECOLOGICAL NURSING TIUEATMENT 

Time allowed x hm 

must answer Tw) quesUons^ and not more than Two. One question must 
be taken Jinm Section A — Surger)^ and Surgical Nursing Treatment and one question firm 
Sectim B-^ynoecology and Crynaeeologkal Nursing Treatment. 

A. — SUROBRY AND SuROXCAL N^UtSINO TrRATUBOT 

l» Describe in detail the poit*operative nursing care after rib resec- 
tion for empyima of 



8i4 AWBN01X 

SI. Apati<mti 0 adimtt«d tm<x>^xc^usas tbereanilt ofA sev^ 

jury. How would you nurse tiac case, imd wfaat observations would 
you make and record? 

B. — ^Gynaecology and Gynaecological Nuesing Treatment 

3. What is a pyotalpnx, and how docs it arise? How would you pre^ 
pare a patient for operation for this condition? 

4. Descrite the symptoms which may be caused by a fibroid tumour 
of the uterus, and discuss the after care of a patient operated upon 
for this condition. 


GENERAL NURSING 


Tim aUowid 2 hours 


Compulsofy. i. 
Compulsoiy^ s. 

4 * 

5 ^ 


Describe the nursing care of a patient sufiering from Lobar Pneu> 
moi^« What complications are likely to occur? 

Give a full account of the immediate post-operative nursing and 
the after care of a patient who has had tonsils and adenoids re- 
moved. 

What do you understand by a narcotic poison? Name one and des- 
cribe the symptoms which would be produced by swallowing it. 
Pending medical aid, what first-aid treatment would you give a 
person suffering from narcotic poisoning? 

How would you prepare the following: 

(a) Alkaline Bath; 

(b) Mustard Bath; 

(c) Hot Bath? 

For what conditions would these baths be ordered? 

Give a detailed account of your instructions to a junior nurse who 
is to assist you in the routine treatment for the prevention of bed- 
sores in a number of helpless, bed-ridden patients. 


September 1943 

MEDICINE AND MEDICAL NURSING TREATMENT 
Time allowed i hour 

Compulsory, i . To what symptoms may Uraemia give risi? How may Uraemia be 
treated? 

2. What symptoms may Gall-stones cause? What medical treatment 
may be given to a patient with gall-stones? 

3. What is meant by Cotoimry Thromlxxus? What symptoms does it 
cause and how may it be treated? 


SURGERV AND GYNAECOLOGY and SURGICAL AND 
GYNAECOLOGICAL NURSING TREATMENT 

Tme aUowed 1 how 

Nom. — Tou must miswer Two ques^ans, ami mm than Tm* One question must be 
idm from Section and Shergiced Nursing Treatment and one question from 

Section B-^ynamlogy and (Synaeeokgkal Nursing 

A.-— SxmOERY AND SimOICAL NimStNO TRBATliSBirr 

1. A iniaii is axinfilted sv^bring fmm isveie bums of the abdominal 
walk Discuss the treatomil and wMug tMd. 



QJUBSTXONfi 815 

2. What is a gastroitany^ and for what conididons may it be per* 
formed? Discuss the nurskig care erf a patient after this operation 
has been done* 

8.--*GYNABOOtboy AND Gynabcolooigal NtJRsmo Tkeatobot 

3. Discuss the symptoms that may be caused by an ovarian cyst. How 
wpuhl you prepare a patient for operation for its removal? 

4* What is (4) a rectocele and {b) a cystocele? What symptoms may 
tjtwy caiaapi and how may they be treated? 


GENERAL NURSING 
Tim allowed 2 hours 


Cotnfmlsofy* 

Compulsory. 


I* Give an account of the nursing of a patient who is to have ‘abso- 
lute rest*. 

2. Describe the nursing of a patient after a radical amputation of the 
breast. Your account should cover the period from when the 
patient leaves the theatre to the end of the first week. 

3« State the action^ average dose and method of administration of the 
following: 

{a) Pilocarpine, 

{b) Omnopon. 

(e) Quinine sulphate. 

(d) Belladonna. 

(e) Sodium salicylate. 

4. Mention three of the commoner conditions for which a vaginal 
douche may be ordered. What preparation would you make for 

f iving the douche? 

tate the various uses of the following in nursing treatment: 

(a) Ice. 

(b) Glucose. 

(c) Tinct. Benzoin Co. 


April 1944 

MEDICINE and MEDICAL NURSING TREATMENT 
Time allowed 1 hour 

Compulsory, i. To what causes may Jaundice be due? 

Describe the non-surgical treatment of one of these causes. 

2. What is meant by Peripheral Neuritis? To what causes may it be 
due and to what symptoms may it give rise? 

3. What appearances would lead you to suspect Pediculosis Capitis, 
Scabies, Ringworm? OutKne the treatment for one of theac.^ 


SURGERY AND GYNAECOLOGY and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Tim aU(m>ed i how 

Note. — Tou must answer Two questionr^ and not mm than Two. One question must 
be taken from Section A^-^urgery arid Skrgml Pfursii^ Treatment-^-and one question from 
Section B-^Qynaecol^ and GynaeeoldgM Jfutsir^ Treaimeni. 



8l6 APPENDIX 

A. — Surgery and Suroigai. Nursino 

1, Discuss the nursing care after an operation for gangrenous 
appendicitis for which drainage has been employed* 

a* Discuss the nursing management of a patient admitted with a 
compound fracture of the fcmm. 

B. — Gynaecsology and Gynabooloqigal NuRsmo Treatment 

3. What is meant by the term ectopic gestation ? What compUca* 
tion commonly results from this condition and how is it treated? 

4. Describe the condition known as prolapse of the uterus. What 
symptoms may it cause^ and how may it be treated? 


GENERAL NURSING 
Time allowed 2 hours 


Corr^mlsary. 

Compulsoc^. 


1 . Describe fully the nursing care, feeding and general management 
of a case of gastro-enteritis in a child. 

2. Give a full accoimt of the nursing of a patient who has under- 
gone an operation for acute mastoid dis^e. 

3. How would you prepare one pint of each of the following: 


(а) Normal saline. 

(б) Acriflavinc i~8ooo from a solution of i-iooo* 

(c) Hydrogen peroxide 2.5 volumes from a 10 volume stock 
supply. 

For what purposes may these preparations be used? 

4. What is meant by Apoplexy (stroke) ? How is it caused? Describe 
the nursing of a patient during an apoplectic seizure. 

5. For what purposes are the following instruments used, and how 
arc they sterilized: 


(a) A Cystoscopc; 

(b) Gum elastic Catheter; 

(c) Steinmaxm’s Pin; 

(d) Hodge’s Pessary; 

(e) Ryle’s Tube? 


September 1944 

MEDiaNE and medical NURSING TREATMENT 
Time allowed i hour 

Compulsmy. 1. What are the causes of vomiting of blood (haematemesis)? 

Describe the medical and nursing treatment of a severe case. 

2. Describe a rigor« In what conditions may rigors occur and what 
is the nursing treatment <£ this symptom? 

3. State briefly what you know about; — 

(a) Erythema nodosum; 

Ih) The compBcadons of measles; 

(c) Thrush; 

{d) Overdosage of d^italis; 

(e) Nikethamide (Goramine). 



QUBSnoM 


817 

Sbptsmbbr 1944 

SURGERY AND GYNAECOLOGY and SURGICAL and 
GYNAECOLOGICAL NURSING TREATMENT 

Time allowed i hour 

A. — SuROBRY and Surgical Nurhng Treatment 

!• Describe the symptoms of a patient suffering from strangulated 
hernia. Descril^ the nursing of a patient who has had an opera* 
tion for the relief of this condition. 

2. How would you nurse a patient who has been admitted as an air- 
raid casualty sufioring from lacerations of the buttock and thigh? 

B. — Gynaecology and Gynaecological Nursing Treatment 

3. What is an Ovarian Cyst? Describe the complications that may 
occur. Describe the nursing of a patient from whom an ovarian 
cyst has been removed. 

4. What arc the causes of severe uterine haemorrhage? Describe the 
treatment and nursing care of any one of these. 


GENERAL NURSING 
Time allowed 2 hours 

Compulsory, i . What precautions should be taken to prevent the spread of infec- 
tion from a patient in a general ward suffering from active pul- 
monary tub^ulosis? 

Compulsory, 2. How would you nurse a patient who is unconscious owing to a 
severe head injury? What observations would you make and 
record? 

3. Describe the diet which may be ordered in the following diseases : 

(a) Ulcerative colitis; 

(b) Acute nephritis. 

State briefly the reasons for such special diets in these two diseases. 

4. What chest complications may follow an abdominal operation? 
How arc they prevented? What treatment would you expect to 
give if they occur? 

5. For what conditions may gastric lavage be ordered ?What prepara- 
tion would you make? Describe in detail how the procedure is 
carried out. 




Index 


Abdomen, examination of, 26 
tapping of, requmles for, 

Abdomiw cxmcutiom, acute, 054 
distcniton, post<<>pa:ative, 639 
gynaecolo^cal operations, pro* and post* 
operative care, 513 
hysterectomy, 510 
swabs, 619-21 
me^od of stitching, 620 
Abortus fever, see Undidant, 449 
Abscess, 557* 559 
Bartholin's, 520 
cerebral, in mastoiditis, 724 
cold, 780 

embolic, in endocarditis, 349 
in diabi^es, 438 
lachrymal, 745 
liver, 395 

in dysentery, 451 
metastatic, in pyaemia, 558 
opening of, instruments for, 616 
psoas, 780 
stitch, 581, 644 

subphrenic, post-operative, 648 
tub^culous, 780 
Aceta, 295 

Acetonaemia in diabetes, 438 
Acetone in urine, tests for, 62 
Achlorhydria in pernicious aiiaemia, 360 
Add ba&, X 17 

Acids, corrosive, poisoning by, 333 
Acoumeter, 702 
Acromegaly, 437 
Act, Dangerous Drugs, 332 
Pharmacy and Poisons, 1933, 322 
Acupuncture, 205 
Acute abdominal conditions, 654 
infections, 442-58 
Addison's anaemia, 360 
disease, 435 

blood pressure in, 358 
Adenitis, 3^ 
simple, 303 
suppurative, 363 
tuberculous, 363 
Adenomata, 574 
Adhesions in {^pde ulcer, 380 
Administration of oxygen, 321-4 
Admission bath, 23 
bed, 22 
card, 19 
of children, 22 
of patient, 19 

nbservaltoea on cooditioB of, 23 
xrf women, 22 
Adrenalin in asthma, 369 
Aerated badx, 117 
Afhiixon, 127 

A|SB^udxiin<«nree plasma, too 


Agglutination test, 449 
A^anulocytosis, 361 
Air beds, storage of, 76 
uses of, 84 
cushions, uses of, 84 
hunger in diabetes, 438 
Alastnm, 479 

Albumin in urine, tests for, 60 
water, 267 

Albuminuria of pregnancy, 548 
Alcohol as stimulant, 303 
Alcoholic neuritis, see Neuritis, 412 
Alcpsin, 428 

Alimentary tract, administration of drugs 
by, 316 

inflammation of, 383 
X-ray examination of, 209-10 
Alkaline bath, 117 
fomentation, 91 

Alkalis, corrosive, poisoning by, 333 
Allen’s apparatus, use of, 1 1 4-1 5 
Aloes enema, 13 1 
Alum enema, 1 3 1 
Ambrinc wax, use of, 104 
Amenorrhoca, 530 
Ammonia, inhalation of, 319 
Amoebic dysentery, 451 
liver abscess in, 451 
Amputation bandage, 254 
bed, 80 

instruments for, 689 
of breast, 665 

stump, care of, post-operative, 672 
surgic^, 671 

Amyl nitrite, administration of, 320 
Anaemia, Addison’s, 360 
aplastic, 361 
diet in, 286-7 
pernicious, 360, 437 
diet in, 206-7 
primary, 359 
secondary, 361 
splenic, 362 
varieties of, 359 
Anaesthesia, 62^-30 

general, requisites for, 527, 612 
local, 627 
requisites for, 613 
regional, 627 
sacral, 608 
spinal, 628 

requisites for, 614 
splanchnic, 627 
stages of, 627 
Anaesthetic enema, 132-3 
Anaesthetics, 298, 627-9 
general, 627 
preparation for, 630- x 
vomiting after, 640 


8x9 



820 


INDEX 


Analgwa, s$e Local anacsdiesia^ 627 
Axialyiis, gastxic, 215 
Anaf^ylactic shock, $26 
Aiicurysm, SM^S 
aortic, 355 

treatment of, surgical, 355 
Angina pectoris, 354 

use of amyl nitrite in, 320 
Aniline dyes, use of, 62 1 
Ankle spica, 248 
Anoxaemia, 321 
in gas poisoning, 335 
Anorexia nervosa, 423 
Antenatal care, 545-7 
Antepartum haemorrhage, 549 
Anthelmintic enema, 131 
Anthelmintics, 298 
use of, 388 
Anthrax, 454-5 
Antibactei^ serum, 325 
Antidotes, 299 
for use in poisoning, 333 
Antigen, 326 

Antiphlogistinc, application of, 96 
Antipyretics, 299 
Antiseptic baths, 117, 501 
pastes, 624 
powders, 624 
technique, 607 
Antiseptics, 299 
Antistreptococ^ serum, 325 
Antitetanic serum, prophylactic use of, 455 
Antitoxin serum, 325 
Antitoxins, 299 , 

Antrostomy, intranasal, instruments for, 
716 . 

Antrum, picture of, 726 
requisites for, 707 
Anuria in acute nephritis, 398 
AcHtic disease, symptoms of, 348 
incompetoice, pulse in, 41 
Apericnl^ administration ^,314 
examples of, 302 
in cobc, 344 
in enteritis, 385 
in nephritis, 399 
in peptic ulcer, 381 
poet-operative, £13 
Apex beat of heaut, location of, 40 
Aphasia, 408 
Apicolysis, 494 
Apnoea, 43 

in Cheyne-Stokes breathing, 43 
Apomorphine hydrochloride, 300 
Apoplectic seizure, 408 
Apptfurent amenorrhoea, see Amenorrhoea, 

530 

Appendicectomy, diet after, 642 
instruments for, 685 
Appendicitis^ 856 
Applications, c^d, 93 
goDieral, 111 
hot, 90-3 
leeches, 105-6 
liniment, 101 


Applications, local, 90 
Apidicatogni, radium, varieties 791, 
radon, 524-5 
Apyretic fever, 32 
Aquae, 295 
Arcm semlts, 748 
Argyrol, use of, 623 
Anstol powder, tise of, 624, 652 
Arm, care of, after mastecUmiy, 666 
Arm slin^, iaxge and small, 257 
Arrest t^nleeding, 571 
Arrhythmia, 40 
ArthritiB, 784 

Arsenic, cumulative effect of, 293 
poisoning, 234 
use of, in sy^Uis, 538 
Arsine, W2 
Arterial bleeding, 560 
Arteriosclerosis, 355 
nephritis in, 400 
Arteritis, 356 
ArtiBcial feeding, 1 93-6 
pneumothorax, 494 
Asafoetida enema, 1 3 1 
Ascaris iumbricaides, 388 
Aschheim-Zondek test, 545 
Aseptic fomentation, 92 
technique, 607 
Aspiration, dehmtion of, 202 
of body cavities, 202 
of chest, requisites for, 203 
of pericardial sac, 204 
of pleural cavity, 203 
pneumonia, 370 
post-operative, 646 
Asthma, 369 
csucdiac, 353 
chronic, 369 
sputum in, 65 
Astringent bath, 117 
enema, 131 
Astringents, 299 
Atheroma, 556 
Athlete’s foot, 507 
Athrepsia, 276, see also Maraunus 
Atropme poisoning, 334 
Aura in epilepsy, 427 
Aural drming forceps, 706, 723 
syringe, 722 

Auricular fibrillation, pulse in, 40 
Auscultation tube, 702 
Automatism in epilepsy, 428 
Avertin anaesth^a, 132 
as basal narcotic, 628-9 
Avulsion, phrenic, 494 
Axilla, bandage to cover, 254 

Babies, giving enemata to, 133 
mouth, care of, 49 
prciMturei temperature in, 34 
sfTedmen of tnine from, 66 
BalHiiski*s ii|^ 407 
in myelitii, 417 
Badllary dysentery, 450 
Barillitf ommoi, 454 



tNDBX 


821 


Baei^ 475 

wfiiviniminfbctioiu, 40!i-4 

W*if*r^'47o 
Koch^Wsiks, 746 
iu&ircuhsis, 779 
Ofkmts, 446 

Back pressure in heart disease, 530 
Backrest, use of, 84 
Baker’s dermatitis, 30a 
Bandag^, application of, 245 
materials used ibr, 344 
hrpes of, 2^14-^ 

See also tmm name of bandog and regions 
where used 
uses of, 245 
Bandagii^, 244 
Banti’s disease, 262 
Barbiturates, 620 
Barium meal, 209 

Barker’s lumbar puncture needle, 206 
Barley mucilage enema, 131 
Barrel bandage, 259-60 
Bacrier nursing, 464 
Bartholin’s alMcess, 520 
Basal metabolic rate in thyroid disorders, 
records c^, 433 
narcotics, 628 
Bath, add, 117 
aerated, 117 
alkaline, 117 

antiseptic, in skin diseases, 501 
astringent, 117 
Brandt’s, 125 
deansing, 45-~8 
continuous, 116 
creosote, use of, 319 
emollient, 116 
in ildn diseases, 501 
foam, 117 

* for r^ucdon of fever, 120 
hot, 119 
hot air, 115-16 


preparation o£, 46 
radiant heat, 119 
stimulating, 117 
temperature c^, 46 
vapour, 114 
warm, 116 

Bathing an infant, requisites for and tech- 
nique of, 47-8 
Bed, amputation, 80 
blanket, 81*^ 
card, 20 

piocedure with, on disdmrge of 
patient, 30 
cardiac, 82, 351 
divided, 79 
fracture, 81 
iidation nursing, 464 
medical, 81-2 
opcratbn, 78, 637 
plaster, 81 
renal, 82 
dieumaiismi 82 

treatment o^, on discharge of patient, 30 


Bod, types erf*, 78 
Bedblo^, uses of, 83 
Bedcradles, uses of, 83 
Bedding in febrile case, 36 
materials used for, 72 
Bedmaking oi occup^ bed, 77 
prindples of, 76 
requisites for, 76 
Bedpans, cleansing of, 57 
emptying of, 57 
giving of, 56 
Bedrest, use of, 84 
Bedsores, causes of, 52 
in fracture of spine, 694 
prevention of, requisites for, 53 
sites of, 53 
treatment of, 55 
Bedtablcs, 84 

Belladonna, inhalation of, 320 
plaster, 100 
poisoning, 234 
stupe, 92 
Beirs paL^, 41 1 
Benedict’s test for sugar, 62 
Bicoud^ catheter, 137 
Bier’s suction cups, 109 
Bile in urine, tests for, 61 
Biliary antiseptics, 299 
colic, 344, 394 

Bimanual examination, 28, 516 
Binder, plain, 244 
many-tailed, 244 
Binlodide of mercury, use of, 623 
Bipp paste, 624 
Birtli palsy, 778 
Bismuth, use in syphilis, 539 
Bites, 583 
Bitters, 303 

Bladder, calculus of, 677 
drainage of, 140 

Duke’s apparatus for, 141, 143 
Laurie-Natlian method of, 142 
examination of, 214 
inflammation of, 404 
irrigation of, 140 
requisites for, 140-3 
stone in, 677 

surgical conditions of, 675 
Blanching test, 472 

Blanket bathing, requirites for and tech* 
nique of, 45-6 
bed, 81 
care of, 73 

B.L.B. inhalation oxygen apparatus, 311, 
$22 

Bleeding, see Haemorrhage, 560 
Blepharitis, 745 
Blister, application of, 107 
dres^g of, 108 
flying, 109 
raes, 802 

Bluteii^, r^uisites for, 107 
Blood in urine, 63 
diseases of, 359 
extravasation m, 570 



8s2 

Bloody groupmg of, soo 
in chlorosis, 359 
in faeces, 67 

in pernicious anaemia, 3B0 
in urine, tests for, 6x 
Blood presaore^ estimation of, 41 

4 *» 35 ^ 
diet ti^ 381 
. in bleedi^, 571 
low, 358 
norm^, 41, 357 
serum. 325 

specimen of, collection of, 70 
sugar in hypoglycaemia, 440 
percental m, ai8 
transfusion, 197-201 
continuous, 197 

urea, normal percentage of, 213 
test, 214 

vessels, diseases of, 354-6 
Bloodietting, by wet cupping, 110 
Blue baby, 3^9 

stone, application of, to wounds, 581 
Boas's test meal, 217 
Body cavities, aspiration and drainage 
202-7 
odour, 24 

Boiling test for protein, 60 
Boils, 557 
in diabetfss, 438 
Bones, tuberculosis of, 781 
Boradc lotion, 621 
powder, use of, 624 
Borax ba^, 1 16 
Bordet-Gengou badllus, 475 
Bougies, 295 

Bovine tuberculosis, 482-3 
Bowel action after operation, 643 
habit in constipation, 387-8 
in peptic ulcer, 381 
Bowlegs, 775 

Bowls, stmUzation of, 619 
Brachial neuritis, su Neuritis, 412 
Bradford frame, 81 
Bradycardia, 39 

Brain, operations on, preparation for, 755-7 
Bran bath, 116 
or salt bag, use of, 93 
Brandt^s bath, 125 
Breast, amputation of, 665 
changes m pregnancy, 545 
operations on, 665 
Breath, odour of, 24, 27 
^eathiog, inverse, 43 
stertorous, 43 
stridulant, 43 
Britt’s disease, 397 
Biiliianc green, use ol^ 6ftx 
British equivaUmts metric system, 295 
Bronchiecta^ 368 
compUcaring tnonchitis, 368 
sputum in, 65 
Broochitis, 1^7 

307. 373 

chronic, 308 


mPBX 

Bronchitis, in diabetes, 4$$ 
Broncho-pneuamnia, 37a, 373 
danger c^, in measles, 473 
in whooping cough, 475 . 
primary, 373 
Bronchoscop^ 703^ 722 
Bronchoscopy, 72a 
requisites for, 722 
Bulla, definition of, 4^ 

Buller’s shield, use ofi 747 
Bunion, see Hallos valg^ 773 
Bunyan's treatment of burns, 576 
Btm^*Yeo inhaler, use of, 319 
Bums, 575 
treatment of, 576 

Cachets, 295 
administration of, 315 
Calcification, tuberculous, 780 
Calcium oxylate stone, 676 
Calculus, bladder, 677 
kidney, 676 

Calf lymph, inoculation with, see Vacdiua 

4^ 

prepmtion of, 480 
Calipers, ice-tong, 244 
Callous ulcer, 573 
Callus formation, 597 
Calorie requirements of infants, 273 
value of carbohydrate, 262 
of fat, 263 
of foods, 261-2 
of milk, 266, 273, 274 
of protein, 261 

Camphorated oil, appUcationi of, 101 
Cancer, 789 
area, 789 
diagnosis of, 790 
nursing of, 794 
of uterus, 532 
Canenim oris, 383 
Cantharides, use of, 107 
Cap, theatre, 608 
Capacity, measure of, 294 
Capillaxy bleeding, 569 
Capsules, 295 
Carbohydrates, 261, 262 
Carbolic acid poisoning, 333 
as disinfecta^ 622 
bath, 1x7 
Carboluri^ 333 

Carbon dioxnde, administration of. 32a 
bath, 1 18 

monoxide poisoning, 335 
Carbuncle, 557 

back of ne^ bandage for, 254 
in diabetes, 438 
Carcinoma, see Cancer, 789 
Cardiac asthma, 353 
bed, 82, 351 
conations, diet in, 281 
cyde, 38 
failure, 250, 353 
in dsphtfama, 471 
m imetiiiiopt% 37SH3 



833 


Cardiac 39 , 

infarction, 354. 
ayncopc, 353 

Cardio^vdscmar syphilisi 537 
Carie^ tubcrculou#, 781 
Carmichaers teat, use of in cleft palate, 733 
Carminative enema, 131 
Carminatives, 299 
Carpo«peda] spasms in tetany, 436 
Case shee^ procedure with on disoharge of 
patient, 30 

Caseation, tiib^cuious, 780 
Casein, 973 

Castle, intrinsic factor of, 437 
Castor oil ^ema, 130 
Cataplasm, 96 
Cataplasmata, 295 
Cataract, 749 
excision of lens for, 749 
instruments for, 741 
in diabetes, 438 
Catarrh in measles, 473 
Catarrhal conditions of respiratory tract, 

364-5 

conjunctivitis, 745-8 
influenza, 443 

stage in whooping cough, 475 
Catgut, 624 
Cathartics, 302 
Catheter, eustachian, 138 
reaction, 139 
self-retaining, 137 

specimen of urine, observations on, 139 
types of, 137 
Catheterization, 137 
female, 138 
requisites for, 138 
ureteric, 140 

Cauterization of corneal ulcer, 748 
Cellulitis, 557 
pelvic, 554 
C^eals, 262 

Cerebral abscess in mastoiditis, 724 
compression, 601 

haemorrhage, causing apoplexy, 430 
irritation, 

in meningitis, 415 
Cerebrospinal fever, 415 
fluid, specimen, collection of, 69 
Cervicitis, 520 

Cervix, amputation of, 509, 51 1 
jpre- and post-operative care, 51 1 
difatadon of, 509, 51 1 
erosion of, 529 
Chancre, 535 
Chancroid, 549 
Changing a sheet, 152 
Charcot’s joint, 413 
Chart in broncho-pneumonia, 374 
in i^tric add curve, 217 
in heart disease, 351-2 
in pneumonia, 35, 570 
in typhoid fevex^ 
weight of normal m&nt| 275 
Chemical warfare, 801 


INDEX 

Chemotherapy, 327-30 
Chest, aspiration of, requisites for, 903 
Chest, examination of, positions for, 
ChcYne-Stokes breathing, 43 
in uraemia, 401 
Chickenpox, 477 

Children, administration of medicine to, 
admission of, 22 

Chlorine group of disinfectants, 623 
Chloroform anaesthesia, 627 
poisoning, 334 
Chlorosis, 359 
Gholagogucs, 300, 30a 
Cholecystectomy, instruments for, 688 
Cholecystitis, acute, 394 
chronic, 394 

Cholecystography, 2x1, 395 
Chondroma, 574 
Chorea, 421 

Chorio-carcinoma of uterus, 534 
Cigarettes, drug, 295 
Circulation, collateral, 355 
failure of, 350 

Circulatory system, disorders of, common 
symptoms of, 337, 350 
Circumoral region in scarlet fever, 472 
Cirrhosis of liver, 395 
Cisternal puncture, 207 
Citrated milk, 266, 274 
Classification of drugs, 298 
Clawfoot, 773 
Oeansing baths, 45-8 
enema, 128 
Cleft palate, 733-4 
Clonic stage of flts, 427 
Closed plaster methed, 242 
Clothing in pneumonia, 371 
Clubfoot, congenital, 769 
treatment of 769 
Coal-tar preparations, 622 
Cocaine poisoning, 3^4 
Coeliac disease, diet m, 291 
Coffee enema, 132 
Coffee-grounds vomit, 380, 569 
Cold al^cess, 780 
application of, 93 
tor headache, 343 
for inflammation, 560 
general, X20 
pack, 124 
Colic, 043 
renal, 676 
Colitis, 385 
diet in, 288 

muco-membranous, 385 
mucous, 385 
ulcerative, 385 
CoUapse in pneumonia, 372 
temperature in, 32 
therapy, 493 
Colles’s fracftire^ 596 
CoUodia, 205 
Collodion dressing, 653 

application of, to face, 579 



824 

Collodian» vesicans, 205 
appiicmticm of, icB 
Ck>Uoaiom, 295 
Colunarium, 996 
Collyrium, 296 
Colon^ cancer of, 789 
resection of, 661 
Ck>lomc irrigation, 136 
Colostomy, 661 
instruments for, 686 
Colpo-pcrincorrhaphy, 509 
instruments for, 526 
Colporrhaphy, 509 

prc- and post-operative care, 51 1 
Ciozna, 430 
dial^ti^ 438 
in meningitis, 415 
insulin, 440 

vigil, 446 . . , 

Combmed reaction ui Dick test, 472 
in Schick test, 471 
Common cold, 364-5 
Compress, cold, 94 
Compression, cerebral, 60 1 
Concussion, cerebral, 600 
spinal, 602 
Co^ensed milk, 274 
Condiments, 264 
Condy’s fluid, use of, 622 
Gonfectiones, 295 
Congenital syphilis, 538 
treatment, 539-40 
Congestive dysmenorrhoea, set Dysmenorr- 
boca, 531 

Conjunctivitis, 745-”7 
Constant fever, 32 
Constipation, 387--8 
atomc, 388 
diet in, 287 
in heart disease, 351 
spastic, 388 

tonic or spastic, diet in, 287 
Consumption, see Pulmonary Tuberculosis, 
481-97 

Contmuous dnp transfusion, 197 
Contraction in bums, 575 
in peptic ulcer, 380 

Contractures, deformities arising from, 778 
Volkmann’s, 598, 778 
Contused wound, 577 
Convalescence in typhoid fever, 448 
Convalescent measles serum, 474 
Convulsions in infants, 426 
Cornea, ulcer of, 747-^ 

danger of, in measles, 473 
Coronary emlx>lism, 354 
thromlXMds, 354 
Corpus luteum, 5^ 

Corrigan^i puke, 41 
Corrosive acids, poiseming by, 333 
alkalis, poiswing hy, 333 ^ 

Coryne bacterium, dif^thcrial, 470 
Coryza, 364 
in measles, 473 
Coudf catheter, 137 


Cough, brassy, in aneurysm^ 355 
diy, in imeumonia, 370 
in i^eunsy, 374 
in tuberculosis, 488 
refieac, absence cJT, 754 
whooping, 475-6 
winter, 368 

Counterirritants, 106-9 
in relief of headache, 343 
Counting of swabs, importance of, 620^1 
Cowpox, 480 

Cowa milk, 266, 273; see also Milk, cow*s 
Coxa vara, 775 
Cravat bandage, 257 
Creosote bath, 117 
use of, 319 
Crepitus, 5^ 

Cretinism, 432 

Crisis in pneumonia, false and true, 25, 34, 

372 

tabetic, 413 
Cross infection, 466 
Croton oil, 303 
Crush syndrome, 580 
Crusts in skin diseases, 499 
Crutch palsy, 598 
Crying o{ ixdants, 276 
Cubic space in infectious diseases, 462 
Cubicle system of isolation, 463 
Cumulative effect of dmgs, 293 
Cupping, applications of, 109 
dry, in uraemia, 402 
requisites and method of, 109 
glasses, removal of, i zo 
wet, no 

Curative use of serum, 325 
Curettage, uterine, 509, 51 1 
Cusco’s vaginal spe^um, 28 
Cut throat, 579 
Cyanosis, 44 
Cyclitis, see Iritis, 748 
Cyst, dermoid, 573 
hydatid, 395 
meibonuan, 745 
ovarian, 534 
varieties of, 573 
Cystitis, 404 
acute, 404 

after hysterectomy, 516 
chronic, 404 
Cystoede, 531 

Cystoscopic examination of renal pelvis, 
213 

Cystoscopy, 214 
requisites for, 190 
Cystotomy, suprapubic, 677 

349-50 

Dabs, prqparatkm of, 619 
Dactyktis, tubercutous, 

Dagjman sodium, 329 
Dakink sohxtioin, use of, 623 
Dandruff, remo^ oi^ ^ 

Dangerous Drugs Act, 332 

aD!T,,459 



INDEX 


8*5 


Dead» buying mt 

l>eiitii, signs of appioocmiig, fp&^ 
Doamjpensatkiii^ $37; ^ ^ Ci 
wUrntp 355 

b^^er, 

Decocta> 996 
Deep X»ray thisrapy, 795 
Defidency diteasoi, diet in, 289^1 
Deflected septum, 72n 
Deformities, acquired, 760 
classification of^ 759 
oonaenital* 7 (%q 
in fracture of spine, 604 
in hemiplegia, prevention of, 409 
in surgical tuberculosis, 782 
Dehydradoi^ causes of, 271 
fluid administration in, 270-1 
in infrmts, 276 
in relief d headache, 343 
symptoms of, 196 
Ddirium, 346 


7 

Cardiac 


in pneumonia, 372 
tremens, in surgical cases, 647 
Dementia praecox, 423 
senile, 423 

Demulcents for use in poisoning, 333 
De Peazer’s catheter, 170, 172 
Deposits in urine, 62 
Depressant expectorants, 301 
Dermatitis, s€i Eczema, 502 
Dermatome graft, 673 
Dermoid cyst, 573 
of ovary, 534 

Description of bleeding patient, 570-1 
Desensitixation to serums, 326 
Desquamation in scarlet fever, 472 
Detaciunent of retina, 753 
^dextrocardia, 349 
Diabetes, 438 
dangers 438 
dietetic treatment of, 278 
insipidus, 437 
insulin ti^tment of, 439 
Diabetic coma, 438 
outfit, 306 

patient, education of, 441 
Diacetic add in urine, tests for, 62 
Diaphoretics, 300 
in nephritis, 399 
Diarrhoea, 386 
epidemic, 386 
vcmitiiig tu, 386 
summer, ^6 
Diastole, ^ 

Diastolic blood pressure, 41, 356 
Dick test, 47a 
IMcrodc wave, 3^, 40 
Diet alter operations <m stomach, 658 
caldum balance, 289 
fluid, 2^ 
high caldum, 289 
high caiocie, 263, 289 
Ujjk pfomin, 262 
in fi2phtitis, 279 


Diet, high residue, in atonic consttpatiem, 
287 

in anaonia, 286 
in apoplexy^ 409 
in cnofeq^tis, 394 

in chronic parmchymatous nephritis, 
400 

in codiac disease, 291 
in colitis, 288 
in constipation, 287, 387 
in deficiency diseases, 2B9 
in diabetes, 430 
in diabetes meuitus, 278 
in dysentery, 450-1 
in febrile state, 36, 462 
in gout, 280 

in heart disease, 281, 352 
in hyperchlorhydria, 2S6 
in hyperpiesis, 281, 358 
in hypoodorh^na, 286 
in jaundice, 286, 393 
in nephritis, 279, 399 
in obmity, 283 
in peptic ulcer, 284 
in pneumonia, 372 
in rheumatism, 280 
in rickets, 290 
in scurvy, 291 
in skin oj^ases, 501 
In tuberculosis, 490 
in typhoid fever, 447 
ketogenic, 263, 289 
in pyelitis, 402 
Lenhartz, 284 
liver, 286-7 
low calcium, 289 
low calorie, 288 
low protein, 280 
m nephritis, 399 
low residue, 287 
Meulengra<^t*8, 382 
Moro's apple pu^, 288 
postK>perative, 642-3 
Sippy's, 285 

Dietetics, elementary, 278 
Digestive system, dimrders of, 378 
Digitalis, 352 
cumulative efiect of, 293 
Dilatation of cervix, 509, 51 1 
Diphtheria, 470 
antitoxin, 325 
Dipl<^ 777 
Dilcct laryngoscopy, 722 
Disacchandes, 262 
Discharge from ear, 722 
of infectious cases, 30, 465 
of patients, 28 
sUp,29 

Discission for cataract, 749 
instruments for, 742 
Discomforts, post-operative, 638-40 
Disease, speafic, course ol^ 34 
Disinfectants, 621-4 
Distnfection in dysentery, 450 
in tyfdioid fever, 448 



820 IKDBX 


Diidixfbctioii of patkiit «ftor iofoetiont, 465 
Di8]ocatio:i^ 606 
traiunatiCy 606 

Disordered cardiac acdoni 349*^50 
Disorders of uterus, 530 
DispbK^eots of uterii^ 531 
Disseminated sclerosis, 410 
Distension, abdominal, post-opcsradve, 639 
Diuretics, 500 
in nephnti^ 399 
Divcrg^t spica, 248 
Diverticulitis, acute, 385 
chronic, 3^ 

Dorsal elevated potion, 86 
recumbent position, 86 
Dosage of drugs, 292-3 
Doudiing, na^, 726 
vaginal, 143 
requisites fewr, 

Drainage, bladder, Duke’s apparatus for, 
> 4 ? 

Laurie-Nathan’s apparatus for, 142 
of body cavities, 202 
of scrum, 652 

of subcutaneous tissue, 205 
of wounds, 6 a^ 
tubei, care 01, 65a 
Drastic purgatives, 302 
examples of, 302 
Drawsheets, use of, 73-4 
Dressing after eye operations, 751 
after mastectomy, 666 
after thyroidectomy, 664 
evaporating, 94 
moist, 94 

pressure, for leech bite, 105 
surgical, 619 
mai^ement of, 649 
Dried milk, 274 
plasma, 200 

Droplet infection in tuberculosis, 483 
in whoo|nng cough, 475 
Drugs, administration c^, 316 

modes of, by alimentary canal, 316 
by hyp^ermic in^eetk^ 316, 317 
by intramuscular mjectian, 316, 318 
by skin, 316, 324 

^ subcutaneous injection, 316, 317 
inhaiati^ 319 
intraperitoneal, 316, 318 
intrathecal, 316 
intravenous, 316, ^18 
inunction and ionization, 316, 325 
dassiftcation of, 298 
cumulative effect 293 
dosage of, 292 
idiosyncrasy to, 293 
intolerance to, 293 
origin and source of, 292 
preparation of, 295 
safe custody o^ 313 
standardization of, 292 
tonic, 304 . , . 

untoward wfmptmm of, examples <£, 

m 


Drt^ii^ in lyadacte, 343 

Dry iasp{>4g^^i^ 

requisites and methfid of, 109 
Duke’s apparatus for Madder dramage, HS 
Duodenal uker, diet in, 284 
pain in, 379 

Duodenostomy, feeding by, 195 
Dupuytren’s contracture, 778 
I>%wluun, 437 
Dying, care of, 795 
DynKmtexy, 450 
amoebic, 451 
liver abscess in, 395 
badUary, 450 
cfudemic, 450 
Dy^en(m*hoea, 531 
Dyspepsia, 3^, 383 
acute, 378 
chronic, 578 

Dysphagia in aneurysm, 355 
D^phasia, 408 
D^noea, 43 
causes of, 43 
in pericaroitis, 348 
indications of, 24 
nursing in, 43 
varieties 43 
Dysuria, 406 

Ear, affections of, 723 
treatment of, 72a 
bandage^ 250, 251 
discharging, treatment of, 722 
examination of, requisites 701-2, 721 
foreign body in, 593, 723 
injury of, 570 
insertion of drops in, 723 
nose and throat operation drum, 7x4 
operations, instruments for, 715 
syringing of, 72a 
requisites for, 722 
Easton’s syrup, 304 
Ecchynmis, 570 
Edampsia, 5^ 

Ectopic gestation, see Tubal, 530, 351 
Ectropion, 745 
Eczema, 50a 
in diabetes, 438 

Education of diabetic patient, 441 
Edwards’s, Tudor, empyettia tube, 671, 
690 

Effervescing powders, administration of, 
3*5 

Effusions, pericardial, 347 
pleural, 374 

Egg fitp, preparation of, 267 
Eggs. 266, 267 
calorie value o^ 267 
Elbow spica, 248 
Electric pad, use of, 92 
Element^ dietetk^ 278 
Emadatkm in whom^ cough, 475 
Embolectomy, 377 

Embdsc abscesses in eadocar^txs, 349 



mtmx 


827 


Embolmij, cerebral^ caitsing 430 

pulmtimaiy, 376 

posNip^tivvii^ ^6^ 

Emergeacy blood Irawtidon, ^98 
preparation in piivate houie, 626 
Emetics, 300 
for use in pdokming, 333 
Emollient bath, 116, 501 
Emphyiema, 368 
comc^c^ting bttmdutis,^^3^^ 
surgical, 578 
Emptftttra, 296 
Emplas^m, 96 
Empyema, 375, 671 
complicating bronchitis, 368 
Emulstones, 2^ 

Encephalitis lethargica, 418 
Encephalography, 210 
requisites for, 210 
Endocarditis, 348 
malignant, 349 

Endocardium, warty vegetations of, 348 
Endocervidtis, su Cervicitis, 528 
Endocrine system, disorders cf, 432 
Endometritis, 529 

Endoscopic resection of prostate, 679 
Endosyp^lts, 537 

Enema, administration of to babies, 133 
aloes, 131 
alum, 131 
anaesthrac, 132 
anthelmintic, 131 
asafoetida, 131 
astringent, 131 
barium, 210 
barley mudlage, 131 
carminative, 131 
castor oil, 130 

cleansing admiobtration of, 128 
coffee, 132 
ether, 133 
evacuant, 129 
glycerine, 130 
gum tragacanth, 131 
magnesium sulphate, 1 3 1 
in hyperpi^, 385 
medicinal, 132 
molasses, 131 
normal saline, 132 
nutrient, 132 
olive oil, 130 

and glycerine, 130 
ox bile, 130 
purgative, 130 
quassia, 131 
in threadworms, 431 
rash, 134 
requisites for, 128 
salt and water, 131 
saponis, 130 
seaadve, 131 
sim|4ex, 129 
soap and water, 130 
starch mudlage, i 31 


Enema, starch and ophim^ 131 
stimulattng, 132 
turpentine, 131 
varieties of, 129-32 
Enemata, 296 

Enteric fever, rss Typhoid. 446 
Enteritis, 384 
acute, 384 
chronic, 385 
tuberculous, 779 
Entropion, 745 
Enucleation of eye, 744, 753 
of prostate, 678 
Enuresis, 405 
Epauntin, 428 
Ephedrin in asthma, 369 
Epidemic dysentery, 456 
Epilepsy, 427 
dangers of, 428 
Jacksonian, 429 
major, 427 
minor, 428-9 
Epiphora, 745 

Epistaxis, see Nose bleeding, 569, 724 
Epitheliomata, 574 
Equino-varus, 769 
Erb’s palsy, 778 
Erysif^las, 452 
treatment of, local, 453 
Erythema nodosum, 445 
Er^raemia, 361 
Esmichb test for albumin, 61 
Eserine, use of, in glaucoma, 752 
Essentiae, 296 
Ether anaesthesia, 627 
enema, 133 

Eupad, use of, 623, 624 
Euphoria, 758 
Eusol, use of, 623 
Eustadiian catheter, 138, 721 
Evacuant enema, 129 
Evaporating dressing, 94 
lotion, 94 

Evipan as basal narcotic, 629 
Ewald’s test meal, 2x7 
Examination, bimanual, 28 
gynaecological, 516 
of abdomen, 26 
of chest, 26 
of legs and feet, 27 
of mouth and throat, 27 
of patient, 25 

of rectum, requisites for, 27 
of throat, requisites for, 27 
o[ vagina, 28 
requisite for, 28 
quesnons, 8b&^i8 
Exi^riation in skin diseasi^ 499 
Excreta, collection of spedboiens of, 67 
from infectious case, disinfection 0^ 465 
in typhoid frver, 448 

Excretoi^ system, symptoms exf, in heart 
disease, 350 

Exercises, Frasers, in locomotor ataxia, 

413 



8a8 1 K 0 SX 


Exercises, gredottled in tubarciakMii^ 489 
Exophthaime goitre, 433 
Expectorants, 300 

Expectoration, types of nursing care in, 
„ 64-5 

Extension apparatus, ags 
application of 224, 230-7 
skdetal, 241 
stramni^, 224, 241 
illustration of, 232 
rcQuisites for, 224, 241 
Extrapleural pneumothorax, 495 
Extra systole, pulse in, 40 
Extra-utciine gestation, sei Tubal, 530, 551 
Extracta, 296 

Extravasation of blood, ^70 
Exudation of lymph in inflammation, 558 
Ey«^ bandage, 250 
diseases of, nursing care in, 735 
enucleation of, 753 
examination of, 736 
requisites for, 737 
ford^ body in, 584 
irrigation of, 746 
requisites for, 738, 741, 743 
operation drum for, 740 
speculum, 736, 742 
Eydashes, cutting 750 
Eyelids, affections 01^ 736 
cystt of, 745 

Eyestrain, cause of headache, 342 

Face, expression of, on admission, 23 
observation of, on admission, 23 
wounds of, 579 

Facial eiysipem, see Erysipelas, 453 
Faeces, m Stools, 63 
Fahrenheit scale thermometer, 31 
Failure, cardiac, 353 
circulatory, 350 

Fallopian tuto, inflammation of, 529 
insufflation of, 51 1 
Fats, 261, 262, 263 
Faucial diphtheria, 470 
Favui, 507 

Febrile state, incubation period, 34 
notes on, 34 
nursing 36 
stage of fasbgium, 34 
•stage of invasion, 34 
stage of onset, 34 
symptoms of, 35-6 
Feeding after eye operations, 751 
after intubation, 730 
after laryngectomy, 732 
after op^tions on brain, 757 
an unconscious patient, 754 
artifid^ 193^ 
requisites for, 193 
in chorea, 421 

in harelip and cleft palate, 733 
in whoofnng cough, 476 
nasal, 193 
oesc^ihageal, 194 
patients, 26i-<>72 


Feeding, rectal, 195 
. throu^^ <kK)deii08toaiy qpe^^ 193 
throu^ gastrostomy op<^ng» 19s 
through oesophagotomy qpeiaing, 195 
Feet, examinaaon 27 
Fehling's test ftxr sugar, 62 
Felton*s serum, 370 
Female cathetef^tion, 138 
catheters, 170, 171 
Femoral hernia, 659 

Femur, fractured, in iqilmt and extoouiicm, 

Fergus8on*s vaginal speculum, 28, 521 
Ferric chloride test for acetone, 62 
Fertiliaation, 544 
Fever, 32 

baths for reduction of, 120 
decline of, 3^ 
in tuberculous, 
mode of onset of, 34 
nursing, 462-80 
sponging for reduction of, 121 
therapy in syphilis, 539 
types of, 32 

See aUo vmtr the name offerer 
Fibroids of uterus, 532 
Fibrm^ 574 
Fibrosis, tuberculous, 780 
Figure id eight bandage, 246, 247 
FiHx mas, 299 

in treatment of tapeworms, 368 
Fire danger in spirit dressings, 653 
First aid in bums, 576 
in fractures, 597 
Fissures in skin diseases, 499 
Fistula in peptic ulcer, 3^ 

Fits, apoplectic, 408, 430 
ej^epUc, 427 
hysterical, 429 
uraemic, 

Fixation splint for Rammstedt's operation, 
390 

Flatfoot, 772 

Flatulence, postH>perative, 639 
Flatus tube, to pass, 167 
Flavine, use of, 621 
Flexile collodion, 295, 653 
Fluid diet, 270 

Fluids, administration of, 196, 263, 270 
balance of, in body, 271 
in febrile case, 36 
restriction of, 264 
retention in body, 271 
Fluorescein as eye stain, 748 
Foam baths, 1 1 7 
uses of, 118 

Focal infection from mouth, 50 
Follicular tonsillitis, 727 
Folliculin, 437, 544 
Fomenta, 2^ 

Fomentations, alkaline, 91 
anrisepttc, ^ 
hypertonic saline, 91 
medical, requilites fr>r, go 
pteparation and <90, 



INDEX 829 


FomcxititiMu, inda, gi 

Foodig cUMificiitKin of, 261 
farmacficnis, 863 

iiilTQ|peaM3W 

oi^gi^ and 861 

lerving to parents, 867 
Foot, bap^e for, 847» 248 
defimnitios of, 760 
Forearm, bandage lor, 246 
Foreign body in car, 593, 723 
in eye, 584 
in larynx, 593 
in noee, 593 
in oeso^agus, 593 
in tissues, 584 
in urethra, 59a 
Formal^ use 01, 622 
Four-taili^ banda^, 244, 251, 252 
Fowlcr^s position, 87 
Fractional test meal, 215 
Fracture bed, 81 
Fractures, 595 
See also mder names ef bones 
comminuted, 588, 596 
complete, 596 
compouzid, 596 
depressed, 596 
fissured, 5^ 
peensticK, 596 
healing of, 597 
impacted, 5^ 
incomplete, 596 
mal*union in, 598 
non-union of, 5^ 
repair of, 597 
simple, 596 
treatment of, 597 

Fracnkel's exercises, in locomotor ataxia, 
4 » 3 ^ 

Umgue depressor, 703, 704 
Freeaing, soe Local anaesthesia, 627 
Fresh air in infectious <foease8, 462 
Friedman's test for pregnancy, 545 
Fruits, 065 

Funedonsu nervous disorders, 407, 419 

Gait in C.D.H., 770 
in hemijdegi^ 409 
in Parkmsonism, 418 
in sppdc paraple^a, 777 
tab^c, 413 

Gallbladder, diseases of, 392 
examination of, 211 
non^aurgioal drain^e of, 212 
Gallstones, jaundice in, 392 ^ 
Gans^ioncctomy, sympathetic, 391 
Gangrene, 557, 559, 572 
in diabetes, 428 
Gargarisma, 8^ 

Gargles, 727 

Gas and oxygen anaesthetia, 687 
lemon in g, 335 
Gasm, war, 801 
Gas gangrene^ 557 


Gastrectomy, diet after, 843 
partiali 657 
Gastric anaf)^ 8 15 
influenaa, 303> 443 
lavage, r^uisites lor, 135 
tonics, 304 
ulcer, diet in, 284 
pain in, 379 
Gastritis, 383 
Gastro-c^c fistula, 380 
reflex, irritation of, 387 
GastroHluodenostomy, 657 
Gastro-cntcrostomy, 657 
Gastro-intestinal colic, 343 
influenza, 443 

Gastroptosis, see Visceroptosis, 39 x 
Gastrostomy, feeding by, 195 
General paralysis of insane, 4x4 
Genital tract, inflammation of, ascending, 
520 

Genito-urinary tract, investigation of, 
212-X5, 402 
tubcrculosb of, 783 
Genu-pectoral position, 88 
valgum, 775 
German measles, 474 
Gestation, ectopic, 530, 551 
Gigantism, 437 

Glands, enlargement of, in rubella, 474 
tuberculosis of, 781 
Glandular fever, 456 
Glass slide for collection of blood, 71 
Glaucoma, 752 

trephining of, instruments for, 743 
Glioma, 574 
Globin insulin, 439 
Gloves, surgical, 617 
Glucose tolmnce test, 217-18 
Glycerine bath, 1 1 7 
enema, 130 

of bell^onna, use of, 105 
of borax, use of, 105 
of ichtliyol, use of, 105 
use of, 105 
Glycerines, 296 
Glycosuria in diabetes, 438 
Gk>itre, exophthalmic, 433 
Gold therapy, 786 
Gonococcal conjunctivitis, 747 
Gonorrhoea, 540-2 
vaginal dis^arge in, 67 
Gout, diet in, 280 
Gown, theatre, 617 
Graafian follicles, 543 
Graduated activity m heart disease, 351 
Graham's test, 21 x, 396 
Granules, 296 

Graph of bicKxl pressure, 357 
Graves's disease, 433 
Green stools, 64 
Groin spica, 249 
Groupi^ of blood, 200 
Gum elastic catheter, 137 
tragacanth enema, 131 
Gumma tumours in syphilis, 537 



ago 

eiuuniiiatim 

Gut, resection of, intruments fcMT, 686 
Guttae, sgG 

Gynaecological abdomiiild cases, prev 
|>ost^pera6ve care, 5i5-*t4 
examination, 516 
requisites for, 521 
operations, 509 
treatments, 517 
requisites for, 522 

Haematemesis, 380, 381, 569 
Haematoma, 570 
post-operative, 644 
Haematuria, 569 
in kidney csJculus, 676 
in renal colic, 344 
Haemoglobin, estimation of, 71 
Haemophilia, 361 
Haemopt)™, 375, 569 
first aid in, 3^ 
in tuberculosis, 488 
Haemorrhage, 5^ 
after prostatectomy, 679 
ailer thyroidectomy, 664 
after tonsillectomy, 728^ 
treatment of, requisites for, 710 
antepartum, 549 
cerebral, in hypcrpicsis, 357 
from wounds, 578 
in cancer of uterus, 533 
in peptic ulcer, 379-^ 
in typhoid fever, 447, 449 
internal, symptoms of, 570 
nasal, 724 
post-operative, 645 
p>ost-partum, 551 
pressure points in, 561-6, 571 
types of, 369 
Haemorrhoids, 659-60 
in heart disease, 350 
Hair, care of, 50 
condition of, on admission, 23 
washing of, in bed, requisites Ibr and 
technique of, 51-2 
Halitosis, 24, 27 
Hallux rigidus, 774 
valgus, 763, 773 

Hamilton-lrving apparatus, use of in pros- 
tatectomy, 678 
Hammer toe, 774 
Handkerchi^, paper, use of, 65 
Hands and feet, observation Of, on admis* 
sion, 24 

bandage for, 246 
disinfection of, 6o7*-8 
surgical preparation of, 608 
HarcUp, 732 

Harrises catheter and introducer, 172 
prostatectomy, 678-9 
Harrison's sulcus, 775 
Haustus, 296 
Hay's test for bile salts, 61 
He^ care of, 50 
tine-combing Of, 50 


mmst 

Head, suspension podition, 89 
verminous, trcatmoit of, 51 
Headache, 342 
Healing of wounds, 580--2 
Health of nurse in Mectious dbeftSCS, 470 
In tuberculOsii, 497 
Hearing, testing Of, requites for, 702 
Heart, bilocular, 349 
dise^es of, aoquii^, 347 
bed for, 82 
congenital, 349 
diet in, 281 
functional, 349 
graduated activity in, 351 
organic, 347 
symptoms (^, 350 
treatment of, 351 
varieties of, 347 
disordered action of, 349 
failure, 353 
hypertensive, 357 
hTOcrtrophy of, 400 
infarction of, 354 
table, 84 
trilocular, 349 
Heartblock, pulse in, 39 
Heartburn in dyspepsia, 378 
Heat, application of, diy, 92 
general, 113 
local, 92 

general effects of, 1 1 1 
local, 90 

Hemianopia, 756 
Hemiplegia, 408, 777 
Hepatic function tests, 395'^ 

Hernia, radical repair of, 659 
umbilical, in whooping cough, 475 
varieties of, 659 
Heipes, of Ups, 27 
of nose and lips on admission, 24 
simplex, 507 
xoster, 507 

Hiccup, post^operative, 640 
Higginson's syrmge, 128, ;fo7, 726 
Hip bandage, 249 
oislocation of, congenital, 770 
Hippocratic oa^, 336 
Hirs^prung's diswe, 391 
Hbtamme, 217 
History in antenatal care, 546 
in surgical tubcrculoils, 782 
points in taking, 21 
Hodge's pessaries, 518 
Hodgkins disease, 363 
Hog2 sUnnach in treatment of pernidoui 
anaemia, 360 
Honey, sm Melia, 297 
Hordeolus, see Sty, 736 
Hormone therapy, 330 
Hospital beds, materials used for, 72 
Hot air bath, appUcation of^ 1 i5--t6 
pre^tttions m, 216 
apfdications in intiaxnmatiion, 360 
to eye, 746 
r^uititet for, 738 



mm % 831 


Hot 119 

jpottgNr, m 

3^0 

House, prtvmte, opmtion in, emergency 
pr^>aration, 6«6 
preparation for, €95 
Human convalescent serum, 5^6 
Humanixed milk, 973 
Hutchinson*s teeth, 538 
Hydatki cyst of liver, 595 
H^'drochloric add in acnaonia diet, 987 
in treatment of penddous anaemia, 
360 

Hydrocymxdp add, poisoning by, 334 
Hydrogor, peroxide of, use o^ 6ai 
Hydronf^rosis, 676 
Hydrosalpim^ (|»9 
Hyperaemia in inSammation, 558 
Hy^chlorhydria, diet in, 286 
Hyperextemion in spinal disease, 89 
Hyperparathyroidism, 436 
Hyperpiesis, 41, 336 
danger of, 357 
diet in, 281 
symptoms of, 357 
Hyperpyrexia in rheumatism, 445 
m smallpox, 
temperature m, 31-^ 

Hypertension, 41, 356 
Hyperthermia, after brain operations, 757 
m infants, 391 
Hyperthyroidism, 432-5 
treatment of, medical, 433 
surgical, 435 
Hypertonic dressing;, 91 
Hypertrophy, cardiac, 400 
Hy^odcs, 301 
poisoning by, 335 
Hypochlorhydria, diet in, a86 
Hyjxxicrmic injccdon, 308, 318-17 
preparadon of soludons for, 316 
i^uisitcs for, 305, 316 
syringe, dialing of, 307 
Hyjpodermociysis, 197 
Hypoglycaemia, i|40 
Hypoparathyroidism, 435 
Hypopicsis, 41, 358 
Hy{K>*p]xidu:t>mbmaemui, 804 
Hypostatic pneumonia in fracture of spine, 
603 

in fractures, 598 
prevendon of in coma, 755 
Hypotension, 41, 35ft 
Hysterectomy, abdominal, 510 
for ftbroids, 532 
v««inaL 509, 513 
Wewhcim^s, instruments for, 508 
Hysteria, 420 
Hysteried lit, *429 

Ice poultice, preparadon and application 
of, 95 

tong cahpers, 235, 241 
uses of, p 

Icebag, filmg of, requisites for, 93 


Icebag, use of, 94 
in rigor, 38 
Icecaps, storage of, 94 
Icccradling, 126 
Ichthyol, uses of, 105 
Idiosyncrasy to drugs, 293 
Ileus, paralyde, post-operadvc, 639, 645 
ImpOTOrate hymen, see Amenorrho^ 530 
Imperial system of weights and measures, 

. 294 

ImpetiTO, 503 
starch appficadon in, 99 
Incised wound, 377 
Incompetent valve, 348 
Incontmence of urine, 404 
true, 404 

Indigesdon, 345-^ 

Indigo-carminc dye test, 214 
Indirect laryngoscopy, 701, 721 
Infant, normal stools of, 64 
weaning of, 276 
Infandle convulsions, 426 
paralysis, 410 
causing deformity, 776 
syphilis, see Congenital, 538 
Infants, feeding of, 273-7 

calorie requirements of, 273 
vomiting in, 66, 275 
Infarcdon, cardiac, 354 
pulmonary, 376 
Infection, 557 
from mouth, 50 
in tetanus, 455 
in tuberculosis, 483, 779 
mixed, in tuberculosis, 780 
spread of, in inftuenza, 443 
in Malta fever, 450 
in typhoid fever, 448 
surgical, 557 
Infections, acute, 442-58 
Infectious diseases, 462-80 

treatment of bed on discharge ol 
patient, 30 

Infective end(x;arditis, 349 
skin diseases, 503-5 
jaundice, 392 
Irdcctivity in anthrax, 455 
in measles, 473 
in whooping cough, 475 
Infiltration anaesthesia, see Local anaes- 
thesia, 627 

in spread of cancer of uterus, 532-3 
Inflammation, 558, 654 
of kidneys, 397 
terminations of, 559 
Infiuenxa, 442-4 
gastric, 383, ^3 
prevention of, 443 
Infusa, 296 

Infusion, intravenous, 197 
complications of, 199 
requisites for, 176 
of qiuuttia, 209 

Ingestion of tubercle baeilli> 779 
Inguinal hernia, 659 




mt>%K 


t i i h »i i c ^ o a » anaesthesia, 62 7 
oC tutbcvde bacSH, 779 

370 » 373 
M8t«operaUv€, 646 
Inh^ticmes, 297 
Inhalatidns, drug, 319 

j^» S** 

«aygp^ 322 
tequisttes for, 320 
steam, 320 
in brondutis, 367 
steam kettle, 321 
steam tent, 321 
varieties of, 319 
Injection, hypodermic, 3ib-i7 
intramuscular, 316, 318 
intraperitoneal, 316, 318 
intrathecal, 316 
intravenous, ^x6, 318 
of haemorrhoids, 066 
of varicose veins, 356 
subcutaneous, 31^17 
Injectiones, 297 

Injections, rectal, 196; also Enema, x 
subcutaneous, 197 
Insomnia, 338 
causes ctf, 339 

Inspection of patient, value of, 25 
Instruments for amputation, 6B9 
for antrostmny, 7x6 
for appendicectomy, 685 
for cholecystectomy, 688 
for colostomy, 686 
for colpo-perineorrhaphy, 526 
for decompression, 695 
for discission for cataract, 742 
for embolectomy, 691 
for extraction of lens, 741 
for hysterectomy (Wcrthcim’s), 528 
for internal urethrotomy, 699 
for iridectomy, 742 
for Utholapaj^, 6!^ 
for mastoidectomy, 715 
for needling for cataract, 742 
for nephrectomy, 697 
for prostatectomy (llarris’s), 700 
for resection of gu^ 686 
of nasal septum, 716 
of rib, 690 

lor itraryilated hernia, 687 
for tonsiuectomy, 708 
for tracheotomy, 71 1 
fm: trephining for :g^uGoxn8^ 743 
for uterine duatation and curettage, 5 
sterilization of, 618 
sumcal, general, 682-4 
Insu^tioD of tubm, 51 1 
Insufflationes, 297 
Insulin cxmia, 400 
defidency, 438 
treatment of diabetes, 439-40 
types od^ 439 

Intercostal neuritis, m Neuriits, 412) 
Intermediate bleeding, 570 
Intermittent fever, 32 


secreti^mr^^^^^^crttie sysldiii^ 
Internals of axumals, as artides bl 
International blood groups, 

Interstitial ap^cation of radium, 524^5 
neuritis, sss Neimtii, 412 
Intestinal antisepdcs, 299 
obstruction 654 
resection, instruments for, 686 
Intolerance to drugs, 293 
Intracranial pressure in mctuxtgitis, 4xC 
Intracutjmeous ixjjecttcm, 317 
Intramuscular injection, 3x6, 318 
Intraperitoneal mjecdon, 316, 31B 
Intrathecal administration of drugs, $i{ 
Intratracheal catheter, 138, 170 
Intravenous anaesthesia, 629 
infusion, 197 
iz^ections, 316, 318 
pyelography, 2x3 
uroselectan in, 2x3 
Intrinsic factor of Casde, 437 
Intubation, 729 
Inunction, 316, 324-5 
mercurial, 325 
Invalid feeding, 266-71 
Investigation of genito-urinary tract, 21 

15 

X-ray, 208-13 

See also wider names of organs and region 
Iodine, applications of, 10 x 
bath, II 7 
test for bile, 6x 
use of, 622 
lodism, 293 

Iodoform powder, use of, 624 
Ionization, 316, 325 
Iridectomy, 749 
for glaucozna, 752 
instruments for, 742 
Irido-cyditis, 748 
Iritis, 748 
Irreguis^ fever, 32 
Irrigation of empyema wouiwl, 671 
of eye, 746 
high colonic, 136 
oTbladder, 140 

Irritation, cerebral, 600, 6ox, 602 
Isolation in epidemic diarrhoea^ 386 
in erysipelas, 453 
in pneumonia, 373 
in typhoid fever, 
in whooping cougn, 476 
methods of, 463-4 

Jacksonian epilepsy, 429 
Jaqucs*s oesophagi feeding tube, 194 
rubber tube, use of^ 135 
Jaundice, 392-4 
acholuric, 392 
dieti%28D 
haemolyttc, 292 
in biliary cmic, 344 
obstructive, 392 
stoob in* 64 



INDEX 


Jiw bandage, ^50-60 
Jointa, injuries 605*^6 
tttberculons of, 781 

i oil’s tuprapubac catheter, 170 
unket, preparation of, 067 

Kahn teat, m Syplulia, 538 
Kangaroo tendon, 624 
Kapu^ 672 
Keradds, 748 
Kemig^s sign in meningococcal menin 
gitii, 

Ketogenic diet, 263, 289 
in pyelitis, 403 
Kettle, steam, 321 
Kidd’s U^tube, 680 

Kidney, abnormalides of, congenital, 67s 
calculus of, 676 
disease, bed 82 
inflammadon of, 397 
leak point of, 218 

pelvis, cystOBCopic examination of, 213 
stone in, 676 
surgical diseases of, 675 
tuberculosis of, 783 
X>ray examinadon of^ 212 
Kirschner’s drill, 235 
Klapp’s suction cups, 109 
KUbs^Loeffler badllus^ 470 
Knee*chest posidon, W 

for rectal examinadon, 28 
pillow, use of, 26 
Knock-knee, 775 
Koch-W0$ks bacillus f 746 
Koplik’s spots, 473 
Kyphosis, 774 

Labour, 550 
obstructed, 550 
stages of, 550 
Lacerated wound, 577 
Lachrymal abscess, 745 
obstrued^ 745 
LacUdbumin, 273 

Lacdc add milk, preparadon of, 267 
Lamdlae, 297 
Laryngectomy, 731 
Lar^mgitis, 3G6 
catarrhal, 366 
in tuberculosis, 489, 492 
Laryngoscope, 703 
Laryngoscof^, 721 
requisites for, 703 
Larynx, cancer 789 
foreign body in, 593 
Latsar’s paste in ecxema, 503 
Last offices, laying out dead, 790 
Laundry irom infecdoui case, d^ntection 
of, 465 

Laune-Nathan method of bladder drain- 
age, 142 

Lavage, colonic, 136 
gas^ 135 
LaxaUves, 301 
example of, 302 

QU 


Lead colic, 343 
poisoning, 5^ 

Leak point of kidney, 218 
Leakage of valve, 348 
Leeches, application of, 105-6 
requisites for, 105 
removal of, 106 
Left lateral posidon, 87 
Legs, bandage for, 247, 248 
examinadon of, 27 
Legumen, 261 

Lcitcr’s coils, applicadon of, 95 
Lemon whey, 207 
Lenhartz diet, 284 
Lens, i^ecdons ot^ 749 
excision of, for cataract, 749 
Lesion, type of, in skin diseases, 498-9 
Leucocytes, migradon of, in inflammation, 

, 55B 

Lcucocytosw, 362 
Lcucopaenia, 362 
Lcucorrhoca, 67 
Leukaemia, 362 
myeloid, 362 
lymphatic, 362 
splcno-mcdullary, 362 
Ligature of aneurysm, 355 
Ligatures, 624-5 
Linctus, 297 
Linen, care of, 73 
condemned, procedure with, 73 
old, uses of, 73 
Linimenta, 297 
Liniments, 101 
101 

Linseed bath, 1 16 
Lipiodol examination, 210 
lipoma, 574 
Li|)s, examination of, 27 
herpes of, 27 

observation of, on admission, 24 
Liquor cpispasticus, use of, 107 
Liquores, 297 
Litholapaxy, 677, 698 
lithopacdion, 530 
Lithotomy positions, 88 

for vaginal examination, 28 
Lithotrite, 677, 698 
Little’s disease, 777 
Liver, abscess of, 395 
in dysentery, 451 
acute ydlow atrophy of, 395 
carcinoma of, secondary, 395 
cirrhosis of, 395 
cocktail, 287 

diet in anaemia, 286, 360 
diseases of, 392 
hydatids of, 395 

treatment of pernicious anaemia, 286, 
360 

Lobar pneumonia, 370 
Lobectomy, 670 
Local anaesthesia, 627 
reaction in Xnray treatment, 794 
luOch-BriUe spectai^, 753 



834 

Lochia, 553 

Lockjaw, SH Tetanus, 455 
Locomotor ataxia, 413 
Looped bandage for jaw, 251, 253 
Lordosis, 774 
Lotions, 297 
evaporating, 94 
surgical, 621-4 

Louse-borne infections, 459-61 
Lower motor neurone lesions, 407 
Lozenges, 298 
Lubricants, intestinal, 302 
Lumbar puncture, 206 

in encephalography, 210 
in uraemia, 402 
requisites for, 180, 185 
Lung irritant gases, 8^ 
massive collapse of, post-operative, 645 
Lupus vulgaris, 504 
Lymphadenoma, 363 
Lymphangitis, 362 
Lymphatic system, diseases of, 362-3 
Lyon’s gallbladder drainage, 212, 396 
Lysis, dehnition of, 34 
in scarlet fever, 34 
in typhoid fever, 34 
Lysol as disinfectant, 622 
pwisoning, 334 

Mackintoshes, 74, 75 
MacLcan's test, 213 
Macule, definition of, 498 
Magill’s intratracheal catheter, 170 
Magnesium sulphate enema, 1 3 1 
in hyperpicsis, 358 
Major epilepsy, 427 
Malar flush, 24 

in heart disease, 348 
Malaria, tertian, rigors in, 37 
Malarial treatment of G.P.L, 414 
Male catheters, 137, 170 
fern, 299 

in treatment of tapeworms, 388 
Malecot’s catheter, 1 70, 1 72 
Malignant endocaiditis, 349 
pustule, 514 
syphilis, 537 
tumour, 573, 574 
Malnutrition, 281-2 
Malta fever, 449 
M & B 693, 328 

Mandelic acid treatment in pyelitis, 403 
Mania, post-operative, 648, 752 
Manic depressive psychoses, 423 
Mantoux’s test, 486 
Marasmus, 276 
lactic acid milk in, 267, 276 
Marriott’s method of continuous blood 
, « transfusion, 198, 199 

method of oxygen administration, 322 
Mask, theatre, 6^ 

Massive collapse of lung, posV< 3 pemiivc, 

645 

Mass miniature radiography, 488 
Mastectomy, radical, ^5 


INDEX 

Mastitis in mumpis, 477 
Mastoid bandage, 250 
double, 251 
Mastoidectomy, 724 
instruments for, 715 
Mastoiditis, 723 
Mattress, care of, 72 
Measles, 473 
dangers of, 473 
German, 474 

Measures and weights, 294 
of capacity, 294 
metric system, 294 
Meconium, 64 
Medical b^, 78-82 
conditions, 336 et seq, 
treatment of peptic ulcer, 379 
Medicinal enema, 132 
Medicines, administration of, 292, 3x4 
to children, 315 
rules for, 313 
Megalocolon, 391 
Meibomian cyst, 745 
Mclaena, 380, 570 
Mella, 297 

Membrane, diphtheritic, 470 
Memory of pain, 341 
Meningitis, 414 
meningococcal, 415 
tuberculous, 415 
Meningococcal meningitis, 415 
Menorrhagia, 531 
Menstruation, 543 
disorders of, 530-1 
painful, 531 

Mercurial inunction, 325 
Mercury bath, 117 
diuretic action of, 300 
group of disinfectants, 623 
poisoning, 335 
use of, in syphilis, 539 
Mersalyl, 300, 353 
Metastatic swelling in mumps, 477 
Metatarsalria, Morton’s, 773 
Methyl violet, use of, 62 1 
Methylated spirit, use of, 633, 757 
Metric system, 294 

British equivalents of, 295 
Metritis, 529 

Metrorrhagia, 531; see also Cancer of 
uterus, 532-3 
Michel’s clips, 624 
Micturition, disoiders of, 404-6 
Miliary tuberculosis, 483 
Klilk, caloric value 266, 274 
dtrated, 266, 273 
condemod, 274 
cow’s, composition of, 273 
modifications of, 273 
dried, 274 

human, composition of, 273 
humimized, 273 
jelly, preparation of, 267 
lactic add, 267, 276 
peptonized, 2^ 



835 


INDEX 


Milk, preparation of, for invalid feedings 

skimmed, 267 
uses of, 266 
Minor epilepsy, 42B 
Miscarriage, 549 
Misturae, 297 

Mitral duease, symptoms of, 348 
Moist dressing, 94 
Molasses enema, 131 
Monaldi drainage, 495 
Monoplegia, 777 
Monosaccharides, 262 
Morbilli, S0€ Measles, 473 
Morning sickness, 545, 547 
Moro*s apple pur6e diet, 288 
Morton’s mctatarsalgia, 773 
Motor neurone, 407 
Mouth, baby’s, care of, 49 
care of, 4^50 

cleansing of requisites for and technique 
of, 4^ 

examination of, 27 
neglected, complications of, 50 
observation of, on admission, 24 
temperature in, to take, 33 
Muco-purulcnt conjunctivitis, 746 
Mucus in urine, 63 

Multiple peripheral neuritis, see Neuritis, 

sclerosis, 410 
Mumjps, 476 
Muscle, injuries of, 582 
Muscular rheumatism, 787 
Muscular spasm in tetanus, 455 
Mustard bath, 1 1 7 
leaf application, 100 
plaster, 100 
Myelitis, 4x7 
acute transverse, 41 7 
Myocarditis, 349 

Myoma, su Uterus, fibroids of, 532, 574 
Myomectomy, 510 
for fibroids, 532 
Myotics, 301 
Myringotomy, 723 
requisites for, 706 
Myxoedema, 432 

Nails, care of, 46 

Napier’s cup and stem pessary, 519 
Narcotics, 301 
tjiasal, 628 

basal anaesthetic, 132 
poisoning by, 335 
Nasal feeding, 193 
NativcUe’s ^anulcs, 296 
Nausea in dyspepsia, 378 
in jaundice, 393 
Nebulae, 297 

Neck, back of, bandage for, 254 
glands of, bandage for, 352-3 
side of, bandage for, 352-3 
Needle in tissues, 584 
Needles, surgical, 625, 681 


Needling for cataract, 749 
instruments for, 742 
Nebon’s inhaler, 320, 321 
Nembutal as ba^ narcotic, 629 
Neoplasm, 573 
Nephrectomy, 676 
instruments for, 697 
Nephritb, 397 
acute, J98 
diet m, 279 
chronic, 279, 397, 400 
diet in^ 279, 280 
interstitial, 280, 397, 400 
parenchymatous, 400 
tubular, 397, 400 
dietetic treatment of, 279 
interstitial, diet in, 2B0 
parenchymatous, diet in, 279 
suppurative, 675 
Nephrolithotomy, 676 
Nephropexy, 676 
Nephrosb, 397, 400 
diet in, 279 
Nephrotomy, 676 
Nerve, injuries of, 582 
Nervous system, common symptoms of, 

^.338 

diseases of, 407 et seq, 
symptoms of, in heart disease, 350 
Ncttlerash, see Urticaria, 501 
Neuralgia, 419 
Neuritis, 412 

Neurological examination, requisites for, 

694 

Neurone, 407 
Neurosb, 424 
Ncurosyphilis, 537 

Neurotic vomiung in pregnancy, 547 
Night blindness, 291 
Night sweats, 4^, 489, 4^2 
Nitric acid test for ^bumm, 60 
Nitrous oxide gas anaesthesia, 627 
Nits, removal of, 51 
Nocturnal enuresb, 405 
Nodule, definition of, 498 
Normal saline, 621 
Nose, affections of, 721, 724 
bleeding, 569, 724 
after septum resection, 725 
blowing, 726 
cleansing of, 49 
douching of, 726 

examination of, requbites for, 701 
foreign body in, 593 
infection of, 726 
insertion of drops into, 726 
irritant gases, B02 
observation of, on admission, 24 
obstruction of, 724 
operations, instruments for, 716 
sniffs, 726 
Novurit, 353 

Nummular sputum, 64, 489 
Nurse, avoidance of infixtion by, 470, 
497 



IN0SX 


836 

Nursing, first impr^ons of patient, 19 
in heart disease, 351 
in insomnia, 33B 
in pernicious anaemia, 360 
ormopacdic, 759 
positions us^ in, 86-^ 

See also under name of position 

postK)pcrative, 636 

principles of, 15 ^ 

psychological factor in, 16 

st^, protection of, in radium watxls, 703 

suggestion in, 16 

surgical, 556 

unpleasant duties must not be shirked, 

. 17 

Nutrient enema, 1 3a 

Nystagmus in disseminated sclerosis, 410 

Oatmeal bath, 116 
Obesity, causes and treatment of, 282 
Objective symptoms, 337 
Observation in skin diseases, 501 
on admission, 23 
Obstruction, vjJvular, 348 
Obstructive dysmenorrhoea, see Dysmenor- 
rhoea, 531 

Occult blood in peptic ulcer, 380 
Odour from body, 23 
of breath, 23, 27 
Oedema, diet in, 264, 279 
in heart disease, 350, 353 
Oesophageal feeding, 194 
Ocsophagoscopc, 704, 722 
Oesophagoscopy, 722 
requisites for, 704 
Oesophagotomy, feeding by, 195 
Oesophagus, cancer of, 789 
foreign body in, 593 
Oestrin, 437, 544 

Oily preparations, administration of, 315 
Ointments, applications of, 102 
blistering, application of, 107-8 
Olca, 297 
Oleothorax, 494 
Olive-headed catheter, 137, 170 
oil and glycerine enema, 130 
oil enema, 1 30 
Oophorectomy, 510 

Opening an abscess, instruments for, 616 
Operation bed, 78, 637 

drum, contents of, 61 1 
for ear, nose and throat, 714 
for eye, 740 

in house, preparation for, 625 
on child, permission for from parents, 22 
permission for, 20 
wounds, care of, 644 
complications of, 641 
Operations, gynaecological, 509 
perineal, 509 
preparation for, 630 
vaginal, 509 

Ophthalmia neonatorum, 747 
Oi»um plaster, 100 
stupe, 92 


Orchitis in mumps, 477 
retention of unne in, 405 
Organic nervous diseases, 407 
Ordiopaedic nursing, 759 
Orthopnoca, 43 
Orthopnoeic position, 89 
Osier’s disease, 361 
Osteitis fibrosa, 436 
Osteo-arthritis, 784 
Osteochondritis, 774 
Osteoclasis performed in rickets, 775 
Osteoma, 574 
Osteomych^ 595, 781 
Osteotomy of femur performed in rickets, 
775 

Otitis media, 723 

Otorrhoea in inmetious diseases, 463 
Ovarian secretions, functions, 437 
Ovariotomy, 510 
Ovaritis in mumps, 477 
Ovi^, abscess of, 529, 534 
diseases of, 534 
hormones of, 544 
tumour of, 534 
Overall, isolation, use of, 464 
Ovulation, 543 
Ox bile enema, 130 
Oxalic acid poisoning, 334 
Oxygen, administration of, 321 
B.L.B. apparatus, 322 
Marriott’s method, 322 
rate of, 322 
requisites for, 322 
tent, 323 

Tudor Edwards’s method, 322 
bath, ii8 

cylinder, described and use of, 322 
Oxyuris vermiadaris, 388 

Pack, cold, 124 
hot dry, 113 
hot wet, 1 1 1 

Paget’s disease of bone, 595 
Pain, 341 

after operation, 638 
in angina pectoris, 354 
in duoden^ ulcer, 379 
in gastric ulcer,. 379 
in intestinal obstruction, 654 
in pericarditis, 347 
in pleurisy, 374 
observation on, 342 
varieties of, 341 
Painful dressing, care in, 652 
Pains, serum, 326 
Painter’s colic, 343 
Painting the throat, 727 
Palate, cleft, 733 
Palpation, value of, 25 
Pancreas, disorders of, 438 
Pancreatitis in mumps, 477 
Pan-hysterectomy, 510 
Papillomata, 574 
Papule, definition of, 498 
Paracentesis abdominis, requisites for^ 205 



INDEX 


837 


Pimcetitesk, definiidon ^oa 
Paraffin wax» use of, X04 
Paraldehyde as basal xmrcotic, 628 
Paralysis agiuuxs, 420 
l^eral, of insane, 414 
m fracture of spine, 60a 
infantile, 410, 776 
palatal, in diphtheria, 471 
Paral^c ileus, 639, 645 
torticollis, 771 
Paraplegia, 409, 777 
spastic, 777 

Parathyioia glands, disorders of, 435 
Parktnsomsm, 418 

Parkinson's disease, su Paralysis agitans, 
^0 

Parotitis, specific, 476 
Paroxysms in whooping cough, 475 
Parrish's chemical food, 304 
Partial thyroidectomy, 663 
Pastes, 297 
antbep^, 624 
use of, in eczema, 503 
Patch test, 487 
Patella, fi-acture of, 596 
Patent ductus arteriosus, 349 
Patients, admission of, 19 
bathing of, 45 
clothing of, 20 

contact with infection before admission, 
21 

discharge of, 28 
examination of, 25 
p>reparation for, 25 
feeding of, 261 
histopr of, 21 
Joints in taking, 2 1 
lifting and moving of, in bed, 77 
mon^ and valuables of, 2 1 
physical examination of, 25 
preparation of, for examination, 25 
for vaginal examination, 28 
rccci>tion of, 19 

relatives of, information from, 20 
serving food to, 277 
toilet of, 45 
transfer cA^ 29 

wearing radium, care of, 792 
Paul's tube for drainage of colon, 661 
Pavilion system of isolation, 463 
Pea soup stools, 446 
Pearson bed, 81 
Pedicle graft, 674 
Pedicuk^ 505 

Pelletierinc tannate in treatment of tape- 
worm, 389 
Pelvic cellulttis, 554 

Pelvis, contracted, danger in labour, 550 
fractures of, 604 
Pemphig^, 504 
Penetrating wounds, 577 
Penicillin^ 330 

Pentothal as basal narcotic, 629 
Peptic ulcer, 379 
diet in, 284 


Peptic ulcer, {>rinciples of treatment of, 379 
Peotonked milk, 266 
Pcrchloridc of mercury, use of, 623 
Percussion, value of, 25 
Perforation in typhoid fever, 447, 449 
of viscera, 655 

Pericardial sac, aspiration o^ 204 
Pericarditis, 347 
Pericardium, adherent, 347 
Perineal excision of rectum, 662 
operations, 509 
preparation for, 51 1 
Perineorrhaphy, 511-13 
pre- and post-operative care, 51 1 
Periostitis, 595, 781 
Peritonitis, post-operative, 648 
Pcrlcs, 297 

Permanganate of potash, see Condy's 
fluid, 622 

Permeation in spread of cancer of uterus, 


^ . 532, 533 . 

Permcious anaemia, 286, 359, 360 
vomiting in pregnancy, 547 
Pemocton as basal narcotic, 629 
Peroxide of hydrogen, use of, 62 1 
Pertussis, see Whooping cough, 475 
Pcs cavus, see Clawfoot, 773 
Pessaria, 297 
Pessaries, 518 
Petechial bleeding, 570 
Petit mal, 428 

Peyer's patches, inflammation of, 446 
Pharmacy and Poisons Act 1933, 332 
Pharyngitis, acute, 365 
chronic, 366 

Phenol group of disinfectants, 622 
Phlebitis, 356 

Phlegmasia alba dolens, 554 
Phosphorus bums, 577 
poisoning, 335 
Photophobia, 748 
in measles, 473 
Phrenic avulsion, 494 
Phrenicotomy, 494 

Phthisis, see Pulmonary tuberculosis, 481 

Physical examination, technique of, 25 

Picric acid as disinfectant, 623 

Pigeon breast, 775 

Pigmentation in skin diseases, 499 

Pigmentum, 297 

Pil. colocynth, 303 

Piles, see Haemorrhoids, 659 

Pillowcases, care of, 73 

Pillows, care of, 72 

Pills, administration of, 315 

Pillulae, 298 

Pilocarpine, care in administration of, 113 
in nephritis, 399 
nitrate, 300 
Pink cy'e, 746 

Pituita^ gland, disorders of, 436 
Pituitrm, functions of, 437 
Placenta praevia, 549 
Plasma and serum, 200 
Plaster, 96 



838 

Piaster bed, 81 
belladonna, xoo 
blistering, application of, ^07 
mustard, 100 

of pari^ application of, 220 
requisites for, 220 
nursing of, 81 
sores, 241 
opium, 100 

Pleural cavity, aspiration of, 203 
Pleurisy, 374 
dry» 374 

in pneumonia, 373 
Pneumonectomy, 670 
Pneumonia, 370 
catarrhal, 373 

characteristic temperature of, 35 
crisis in, 372 
false and true, 34 
danger of, in coma, 754 
hypostatic in fractures, 598 
in fracture of spine, ^3 
in hemiplegia, 408 
prevention of, in coma, 755 
inmgestion in, 345 
influenzal, 443 
post-operative, 646 
Pneumoperitoneum, 494 
Pneumothorax, artificiau, 494 
extrapleural, 495 
^ntaneous, 475, 489 
Poison cupboard, precautions regarding, 

313, 332 

Poisoning, 332-5 
arsenic, 334 
atropine, 334 
belladonna, 334 
carbolic add, 333 
carbon monoxide, 335 
• chloroform, 334 
cocaine, 334 
335 

gastric lavage in, 135 
hydrocyanic acid, 334 
hypnotics, 335 
lead, 334 
iysol 334 
mercury, 335 
narcotic, 335 
oxalic acid, 334 
phosphorus, 335 
prussic add, 334 
salts of lemon, 334 
strychnine, 335 
treatment or, 332 
vermin killer, 335 
weed killer, 334 
Poliomyelitis, acute, 410 
Politzer’s bag, use Of, 702, 721 
Polycythacmia, 361 
Polyneuritis, see Neuritis, 41a 
Polysa^harides, 262 
Polyuria in diabetes, 438 
Poradenitis, ^2 

Portal pyaemia^ post-operative, 648 


mi>EX 

Position adopted in post»operattve peri- 
tonitis, 649 

after tonsUlectomy, 726 
for chest examination, a6 
for rectal examination, aS 
for vaginal cxamlnati<^ a6 
in heart disease, 351 
of patient in bed, 24 
Positions used in nursing, 86^ 

See also under name rf position 
Posseting, 66 

Post-anaesthetic care afrer basal narcotic, 
629 

menopausal bleeding, see Cancer of 
uterus, 533 

Post-nasal sponge, 71^, 725 
Post-operative complications, 644 
mama, 6a8, 75a 
nursing, 636 

Post-part um haemorrhage, 551 
Postural drainage, 89, 369 
Potain's aspirator, use of, 178, 203 
Potassium iodide, use of, in syphilis, 539 
Potato cream, preparation of, 265 
Pott’s disease, 782 
fracture, 5^ 

Poultice, charcoal, 98 
95 

linseed, requisites for, 96-7 
mustard, 98 
removal of, 96, 98, 99 
starch, 99 

Powders, administration c^, 315 
antbcptic, 624 

Pregnancy, albuminuria of, 548 
extra-uterine, 530, 551 
pyelitis of, 550 
signs and symptoms of, 545 
toxaemias of, 547 

Premature babies, temperature, 34 
Preparation for anaesthetics, 630 
for operations, 6^0 
for surgical dressing, 650 
of drugs, 295 
Prescription reading, 312 
Pressure dressing for leech bite, X05 
in treatment of bleeding, 571 
points, 561-6 

Prevention of influenza, 443 
Primary tdeeding, 570 
post-partum haemorrhage, 551 
sore of syphilis, 535 
Private house, infectious case in, 468 
operation in, preparation for, 625 
Proctoclysis, 196 
Proctoscope, use of, 27 
Progestin, 544 
Prolapse of uterus, 531 
Prone position, 86 
Prontosil, 327 

Prophylactic use of scrum, 325 
Prostate gland, endoscopic resection of, 

679 

enlargement of, 678 
enucleation of, 678 



Prostatectomy, 678 
Prostatic catheters, 170 
Protamine insulin, 439 
Protargol, use of, 623 
Protein, 261 
diet, high and low, 282 
in urine, tests for, ^ 

Proteins, complete and incomplete, 261 
Pruritis in diabetes, 438 
Prussic add poisoning, 334 
Pseudo^reaction in Dick test, 472 
in Schick test, 471 
Psoas abscess, 780 
Psoriasis, 503 
Psychosis, 423 
manic depressive, 423 
Ptosis, 745 

Puerperal pyrexia, 552 
sepsis, 5^2 
varieties of, 552-4 
septicaemia, 553 
Puerperium, 550, 552 
Pulmonary complications, post-operative 

embolism, 376 
first aid in, 377 
post-operative, 645 
symptoms in heart disease, 348 
tuberculosis, 481 
• after care in, 493 
in diabetes, 441 
varieties of, 483 
Pulse, 38 
abnormal, 39 
collaping, 41 
Corrigan’s, 41 
counting, 39 
dicrotic, 39, 40 

inequality of, in aneurysm, 355 
intermittent, 40 
irregular, 40 
normal, 38 
characteristics of, 38 
in adult, 38 
in newborn, 38 
in pneumonia, 370 
in typhoid fever, 446 
radial artery, 38 
rapid, 39 
rate of, 39 
ratio of, 38 

-respiration ratio, 38, 42 
rhythm, variations in, 40 
running, 40 
strength of, 40 
taking the, 39 
tension of, 40 
thready, 40 
volume of, 40 
water-hammer, 41 
wave, 39 
wiry, fo 

Pulsus altemans, 40 
Pulv. jalapac co., 298, 30a 
Pulvcres, 298 


m 839 

Puncture, cisternal, 207 
lumbar, 206 
requisites for, 180, 185 
of antrum, 726 
of subcutaneous tissue, 205 
Punctured wound, 577 
Purgative enema, 130 
Purpura, 361 
bleeding in, 560 
Purulent conjunctivitis, 746 
Pus cells in urine, 63 
Pustule, definition of, 49B 
Pyaemia, 553, 558 
pKirtal, post-operative, 648 
Pyelitis, 402 
acute, 402 
chronic, 403 
of pregnancy, 550 
Pyelography, 212 
requisites for, 188 

Pyloric stenosis, congenital hypertrophic, 

389 

Pyogenic infection, 558 
Pyonephrosis, 676 
tuberculous, 783 
Pyosalpinx, 529 
P^cxia, 31 
temperature in, 31 
types of, 32 

Quarantine, 465 
Quassia enema, 13 1 

in threadworms, 389 
infusion of, 299 
Quinsy, 727 

Radial artery pulse, 38, 39 
Radiant heat, applications of, 119 
batlis, 1 1 9 

Radical mastectomy, 665 
Radiogram of fracture-iislocation of 
shoulder, 585 

of fracture of tibia and fibula, 590 
of Pott’s fracture, after treatment, 589 
before treatment, 588 
Radium, 790 

applicators, varieties of, 524-5 
bomb, 791 
effect of, on tissues, 
patients wearing, care of, 792 
reaction, 791 

treatment, after care, 794 
of tuberculous glands, 781 
unit, 791 

wards, protection of staff in, 793 
Radon, 524-5, 791 
applicators, 524-5 

Rammstedt’s operation, preparadon for, 

390 

Rash, enema, 134 
in chickenpox, 477 
in erysipelas, 453 
in measles, 473 
in rubella, 474 
in scarlet fever, 472 



840 

Raih, in tmaUpox, 478 
in syphilis, 536 
in typhoid fever, 446 
presence of, on admission, 24 
prodromal, in measles, 473 
serum, 326 

Reaction {see also Tests) 

, of degeneration, 407 
of urine, 59 
radium, 791 
to pain, 341 

Rcactionaiy bleeding, 570 
Reactions in X*ray treatment, 794 
in radium treatment, 791 
to a vaedne, 327 
Reception of patient, 19 
Rectal dressing in haemorrhoid exdsicMn, 
660 

in perineal excision, 663 
feeding, 195 

saline, enema, requisites fbr, 132 
Rectified spirit, use of, 62 1 
Rcctocele, 532 

Rectum, examination of, requisites for, 

27 

excision of, pcnneal, 662 
prolapse of, in whooping cough, 475 
temperature in, to take, 33 
Re-education in chorea, 422 
Reflex indigestion, 345 
Regional anaesthi^, 627 
Regurgitation of blo^, 348 
Rehfuss test meal, 215 
Relapse in infectious cases, 465 
Relapsing fever, 460 
Remittent fever, 32 
Removal of tracheotomy tube, 731 
Renal ctdic, 344, 676 
efficiency tek, 214 
threshold for sugar, 218 
Report after operation, 641 
Resection of colon, 661 
nasal septum, 725 
instruments for, 716 
of rib, instruments for, 6go 
Resolution in indammation, 559 
Respiration, 41 
abnormal, rate of, 42 
extraordinary mu^es of, use of, 42 
normal, 42 
rate, 42 
ratio, ^ 
recording of, 42 
rhythm of, 42 

Re^iratory antiseptics, 299 
disinfectant, 319 

system, disorders of, common symptoms 

diseases <m, 364 et seq. 

Rest, absolute, 340 

in acute rheumatism, 444 
in chorea, 421 
in haematemesis, 382 
in heart disease, 
in hyperpiesis, 3^ 


tRDEX 

Rest, in hyperthyroidism, 433 
in inflammadc^ 560 
in imeumonia, 371 
in poet-operative shock, 638 
in skin diseases, 500 
in tuberculosis, 4^ 

Resd^ juice, obseWations on, 216 
Restriction of sah, indications for, 264 
Retention of urine, 405-~6, 660 
Retin^ dctadmient of, 753 
Retinitis in diabetes, 438 
Retroversion of uterus, 531 
Return case, 465 
Rhagades, 499 
Rhesus factor, 201 
Rheumatic fever, 444 
Rheumatism, acute, 4^ 
and chronic, diet m, 280 
bed for, 82 
in children, 445 
Rheumatoid arthritb, 784-8 
Rhinitis, 364 

Rhinonhoca, care of nose in, 463 
Rib, resection of, 671 
instruments for, 690 
Ricewater stools, 63 
Rickets, convulsions in, 426 
deformities of, 775 
diet in, 290 
Rickety rosary, 775 
Rigors in septicaemia, 553 
nursing of, 37 
sponging in, 38 
stages of, cold, 37 
bot,37 
•wcating, 37 

temperature during, method of charting, 
37 

Ring pessary, 519 
Ringworm, 506 
Risus sardonicus, 455 
Rodent ulcer, 789 
Roller bandage, 245-6 
Rose’s position, 88 
Rothera’s test for acetone, 62 
Round ligaments, shortening of, 510 
worm, 388 
treatment of, 389 
Rubber goods, care of, 75 
Rubefacients, xo6 
Rubella, 474 
Rupture m musde, 583 
of tendon, 585 

Ruptured ectopac gestation, 551 
tubal gestation, 530, 551 
Ryle’s tube, insertion ofi 216 
use of, 135 

Sacral anaestheria, 628 
St. John’s sling, 258 
St. Vitus’s dax^, m Chorea, 421 
Saiicyl suliffionic add test for albomin, 
61 

Saline enema, 152 
fomentatfon, 91 



INBEX 841 


Saline, notmal, 6ai 
Salivary anliaeptics^ 999 
Salivation in muxn]^, 476 
Saljringectomy, 510, 599 
SalfHn^tls, 599 

SalpingOK>ophorectomy, 510, 529 
Salpingostomy, 510 
Salt am water enema, 152 
retention in body, 272 
Salts, 264 

erf* lemon penning, 334 
Salyigan,353 

Sanatorium nursing, 481-97 
Santonin, 299 

in treatment of roundworm, 389 
Sapracmia, 553* 55 ® 

Sarcoma, 574 
of uterus, 5^4 

Sassafras oil, m head cleansing, 51 
Scabies, 504 
Scalds, 575 

Scale, definition of, 499 
Scalp, care of, post-operative, 757 
wounds of, §78 
Scar, vaccination, 480 
Scarlet fever, 471 

characteristic temperature, 35 
red, use of, 621 
Sonring in bums, 575 
in peptic ulcer, 380 
Schick’s test, 471 
Schizophrenia, 423 
Schultz-Charlton’s test, 47a 
Sciatica, see Neuritis, 4x2 
Sclerosis, disseminated, 410 
Scoliosis, 774 
Scott’s dressing, 103 
Scultetus, bandage of, 244 
Scurvy, 291, 804 
bleeding in, 5m 
diet in, 291 
Scybalous stoob, 63 
Sebaceous cyst, 573 
Seborrhoea, 504 
Secondary bleeding, 570 
deposits in sarcoma, 574 
fever in smallpox, 479 
post-partum hemorrhage, 551 
shock in burns^ 575 
sta^ of syphilis, 536 
Sedative enema, 131 
Sedatives in insomnia, 339 
in pneumonia, 372 
Sedimentation rate, 71 
Scidlitz powders, 302 
Setgel’s sp^ulum, use of, 702, 721 
Self-retaining catheters, 137 
SemijpTone position, 87 

tor chest examination, 26 
recumbent position, 86 
for chest examination, 26 
Senile cataract, 749 
dementia, 423 
Sens^ symptoms^ 338 
Sepsis, post-operative, 644, 648 


Sepsis, puerperal, 552 
vaneties of, 552-4 

Septic pneumonia, post-operative, 645 
Septicaemia, 553, 558 
nur^ of, 554 
Septum, defiect^, 724 
submucous resection of, 725 
Scruin, administration of, 326 
antibacterial, 325 
antidiphtheritic, dosage of^ 471 
antiscarlatinal, dosage of, 47a 
antistrcptococcal, 325 
antitetanic, prophyl^tic use Of, 455 
antitoxin, 325 
curative use of, 325 
desensitization to, 326 
Felton’s, 370 
human convalescent, 326 
measles, convalescent, 474 
pains, 326 
preparadon of, 325 
prophylacdc use of, 325 
rash, 326 
sickness, 326 
uses of, 325 

Shaking palsy, see P. agitans, 420 
Shaving the vulva, 517 
Sheep droppings stools, 63 
Sheet, changing of, 77, 152 
Shock after bums, 575 
after operation, 635, 637 
after ruptured ectopic gestation, 530 
after Wertheim’s hysterectomy, 515 
anaphylactic, 326 
Shoulder, bandage to support, 258 
spica, 248, 249 
Sickness, scrum, 326 
Sighing, 42 

Sigmoidoscopy, requisites for, 191 
Silver nitrate, application of, to wounds, 
581 

use of, 623 

Simmonds’s dbease, 437 
Simple purgatives, 302 
Sims’s semiprone position, 87 

for vaginal examination, 28 
vaginal speculum, 28 
Sinus arrhythmia, pulse in, 40 
Sinuses, nasal, infection of, 726 
Sippy’s diet, 285 

Sl^ care of, after eryiipelas, 454 
diseases, 498 et seq. 
history in, importance of, 499 
lesions of, moist, 500 
weeping, 501 
nursing of, 500 
examination of, 499 
fiaps, post-operative care of, 652 
grafting, 673 

itching of, in diabetes, 438 
lesions of, primary, 498 
secondary, 499 

observation of, on admission, 24 
preparation of, for operation, 633 
r^uisites fmr, 615 



842 

Skin^ septic spots on, in diabetes, 438 
temperature of, to take, 33 
Skull, base of, fracture of, 599 
fractures of, 598 
Sleep, disorders of, 359 
importance of, 341 
in heart disease, 351 
in pneumonia, 371 
report on, 340 
Sleeping sidmess, see Encephalitis lethar- 
gica, 418 

Sling bandage, 256--9 

Sloughing, 559 

Smallpox, 478 

Snail-trac^ ulcer, 537 

Snuffles in syphilis, 538 

Soap and water enema, 130 

Soda fomentations, 91 

Sodium amytal as basal narcotic, 629 

Soft sore, 542 

Solutiones, 2^ 

Solutions for hypodermic injections, prepa- 
ration of, 316 
Sordcs, removal of, 49 
Sore, soft, 542 

Sores, splint and plaster of paris, 241 
Southey’s tubes, use erf, 205 
Souttar’s vacuum flask, use of, 1 75 
Spasmodic dysmenorrhoea, see D^mcnor- 
rhoea, 531 
torticollis, 771 
Spastic paraplegia, 777 
Spatula, tongue, use of, 27 
Specific gravity of urine, 58, 59 
estimation erf, 60 

Specimen, collection of, blood, 70 
cerebrospinal fluid, 69 
faeces, 68 
sputum, 69 
urine, 68 
vomit, 69 

Sp>edmens, collection of, 67 
Speculum, eye, 736, 741 
Seiji’s, 702, 721 
vagmal, varieties erf, 28 
Sphygmomanometer, use of, 41 
Spina bifida, 759 
Spinal anaesthesia, 628 
cord, infections of, 417 
Spine, concussion of, 602 
deformities of, 774 
fractures of, ^2 
in rickets, 775 
tuberenilosis of, 782 
Spiral bandage, reverse, 246-*8 
simple, 246-8 

Spirit clressings, use and precautions in, 

653 . 

Splanchmc anaesthesia, 627 
Splenectomy in anaemia, 362 
Splint, fixation, for Raimnstedt’s opera- 
tion, 390 
sores, 241 

Splints, appheation of, 220 
for lower extremity, 222 


INDEX 

Splints for upper extremity, 221 
padding of, requisites for, 225 
varieties of, 220 
Sponge, post-nasal, 714, 725 
Sponging, charting, temperature af^, 
123 

Sponging, exposed, 124 
for reduction of fever, 121 
hot, 119 

in febrile case, 36, 12 1 
in rigor, 38 
tepid, I2i~4 
requisites for, 121, 162 
Spontaneous pneumothorax, 475, 489 
Spore-forming organisms, 537; su also 
Anthrax, 454; tetanus, 455 
Spotted fever, see Cwebrospinal, 415 
Sprains, 605 
Spreading ulcer, 573 

Sputum, characteristics in certain diseases, 

65 

disposal of, 65 
in bronchitis, 367 
in pneumonia, 371, 373 
in tuberculosis, 484, 488, 489 
nummular, 65, 
specimen erf, collection of, 69 
Stab wound of chest, 578 
Stage of irritability in meningitis, 415, 
416 

Stains, removal of, 74 
Standardization of drugs, 292 
Stannard’s envelope, 577 
Starch and opium enema, 131 
bath, 1 16 

mucilage enema, 13 1 
Stasis of blood in infiammadon, 560 
Stationaiy ulcer, 573 
Status epilepticus, 428 
Steam canoj>y, 309, 32 1 
inhalations, 320 
in bronchitis, 367 
kettle, 321 
tent, 32 1 

Stenosis, pyloric, congenital hypertrophic, 

389 

valvular, 348 
Sterile gown, 617 
swab, use of, 70 

Sterilization of articles for operations, 
618 

Stethoscope, use of, 25 
Stimulants, 305 
for use in poisoning, 333 
Stimulating oaths, 117 
enema, 132 
expectorants, 300 
Stinra, 583 

Stitdi abscess, 581, 644 
Stitches, surgicA, fos 
removal of, 625 
rupture of, 644 

Stoeffers operation in paraplegia, 777 
Stomach, cancer of, 7^ 
dilated, 380 



index 843 


Stomach hourglass, 380 
tube, method of introduction, 135, 216 
X-ray examiiiaticm of, 209 
Stomacmes, 303 
Stomatitis, 383 
catarrhal, 303 
simple, 383 
Stone m bladder, 677 
in kidney, 676 

Stools, abnormal characteristics of, 63 
bloK^ in, 64 
fpxcn, 64 
m dysentery, 450 
in jaundice, 393 
in typhoid fever, 446 
norn^ characteristics of, 63 
occult blood in, 69, 380 
of infEuits, 64, 276 
ricewater, 63 
scybalous, 63 
sheep droppings, 63 
specimen of, collection of, 68 
tarry, 64 

Stovaine in spinal anaesthesia, 614. 
Stramoniiun, inhalation of, 320 
Strangulated hernia, instruments for, 687 
Strangury, 676 
Strawberry tongue, 472 
Strychnine, 304 
poisoning, 335 
Stump bai^age, 254 
Stupes, 90, 91 
belladonna, 92 
opium, 92 
turpentine, 91 
Sty, 736 
Styptics, 303 
use of, 57 1 

Subcutaneous injccrion, 197, 316 
saline, administration of, requisites for, 
*75 

tissue, drainage of, 205 
Subjective symptoms, 337 
Submucous resection erf septum, 725 
Subphrenic abscess, post-operative, 648 
Sub-total hysterectomy, 510 
Sugar in urine, tests for, 62 
Sulphanilamide, 327-8 
Sulphathiazole, 328 
Sulphonamide powder, 330, 582 
Sulphur bath, 1 1 7 
ointment in scabies, 505 
Supine position, 86 
Suppositoria, 2^ 

Suppression of urine, 39B 
Suppurative nephritis, 675 
Suprapubic catheter, 1 70 
cystotomy, 667 

Suprarenal gland disorders, 435 
Suigical beds, 78-82 
conditions of bladder, 677"-8o 
<rf kidney, 675-7 
dressings, 61 g 
mana^^ent of, 649 
requisites for, 616 


Surgic^ emphysema, 578 
fomentation, requisites for, 92, 157 
infection, 557, 558 
needles, 625, 681 
stitches, 625 
tuberculosis, 779-83 
Sutures, 624, 681 
secondary, 582 
tension, 582, 625 

Swabs, counting of^ importance of, 620 
preparation of, 619 
Swallowing reflex, absence of, 755 
Sweating in tuberculosis, 489, 492 
Sycosis, 504 
Symptoms, 337 
Syncope, cardiac, 353 
in ble^ing, 571 
Syphilis, 535 
cerebral, 413 
delayed inherited, 538 
of nervous system, 412, 537 
stages of, 536 
Syringe, aural, 705, 722 
care of, 619 

hypodermic, charging of, 307, 317 
Syringing the car, 722 
the throat, 728 
Syrupi, 298 
Systole, 38 

Systolic blood pressure, 41, 356 

T-shaped bandage, 244 
Tabclla, 298 

Tabes dorsalis, see Locomotor ataxia, 
4*3 

mesentcrica, 779 
Tabetic crisis, 413 
gait, 413 
Tablets, 298 
Tachycaniia, 39 
after thyroidectomy, 664 
Taenia medicocanellata^ 388 
solium^ 388 

Talipes calcaneus, 769 
deformities, 769 
cquino-varus, 769 
equinus, 769 
valgus, 7^ 
varus, 769 

Tampons, insertion of, 518 
Tannic acid treatment of bums, 576 
Tapeworm, 388 
treatment of, 388 
Tarry stools, 64 
Tartar emetic, 300 
Tear gases, 802 
Teeth, examination of, 27 
Temperature, 31 

baths for reduction of, 120 
body, normal, 31 
chart of malaria, 37 
of pneumonia, 35 
of rigor, 37 
of scarlet fever, 35 
of tepid sponging, 123 



844 


mDBK 


Temperature, chart of typhc^ fever, 35 
degrees of, 31 
false, 34 
hectic, 32 
in erysipelas, 453 
in measles, 473 
in mouth, to t^e, 33 
in pneumonia, 370 
in premature babies, 34 
in rectum, to take, 33 
in rigor, 37 

in scarlet fever, 35, 472 
in smallpox, 478 
in typhoid, 35, 446 
in tuberculosis, 489 
inverse, 32 
normal, 31 
of skin, to take, 33 
rectal, 33 
reduction of, 28 
subnormal, 32 


Thiamin (vitamin B^), 291, 804 
Thiersch graitt 673 
Thirst io typhoid fever, 446 
post-operative, 640 
Thomas's knee splint, 760 
Thoracentesis, 203 
Thoracoplasty, 495, 666 
Thoracoscopy, 494 
Thorax, surgery of, 666 
Threadworm, 388 
treatment of, 389 
Throat, affcctioiw of, 721, 727 
examination of, 27 
requisites for, 27, 701 
operations, instruments for, 708 
painting of, 727 
syringing of, 728 

Throrabo-phlebitis, femoral, 554, 647 
Thrombosis, cerebml, causing apoolexy, 

. 130 . . 

m hyperpiesis, 358 


swinging, 32 
to take, 32 

variations of, in disease, 31 
in health, 31 
Tender spots, 25 
Tendon, injuries of, 583 
Tenesmus m dysentery, 450 
Teno-synovitis, 583 
Tent, oxygen, 323 
steam, 321 

Terminal disinfection of patient, 465, 
469 

Tertiary stage of syphilis, 536 
Test, agglutination, 449 
Aschheim-Zondek, 545 
blanching, 472 
blood urea, 214 
Dick’s, 472 
Friedman, 545 
glucose tolerance, 217 
Graham’s, 21 1, 296 
indigo-carmine aye, 214 
Kahn, 538 
MacLean’s, 213 
renal efficiency, 214 
Schick’s, 471 
Schultz-Charlton’s, 472 
urea concentration, 213 
Van den Bcrgh, 395 
Van Slyke’s, 214 
Wassermann, 538 
Widal, 449 

Test-meal, Boa 3 % 217 
Ewald’s, 217 
fraction^, 215 
requisites for, 192 
Testes, mal-descent of, 759 
Tetanus, 455 
antitoxin, 299 
Tetany, 435 ^ ^ ^ 

Theatre dress, 608, 617-1B 
Thermometer, clinical, 31-4 
Fahrenheit, 31 
self-registering, 31 


coronary, 354 
Thrush, 49, 383 
Thymol, 299 

Thyroid gland, disorders of, 432 
Thyroidectomy, 663 
Tidal bladder drainage, 142 
Tincturae, 298 
Tinctures, 2^ 

Tinea dreinata, see Ringworm, 506 
tonsurans, see Rin^orm, 506 
Tissues, foreign bodies in, 584 
subcutaneous drainage of, 205 
Toilet in infectious diseases, 463 
Tongue, cancer of, 789 
examination of, 27 
in diabetes^ 438 
in dyspepsia, 378 
in pemidous anaemia, 360 
in pyelitis, 402 
in s<^et fever, 472 
in typhoid fever, 446 
observation of, on admission, 21, 27 
spatula, use of, 27 
Tonic drugs, 304 
stage of fit, 427 
Tonics, gastric, 304 
Tonsillectomy, 728^ 
instruments for, 708 
Tonsillitis, 727 
Tonsils damp, 710 
Torticollis, 771 
Total hysterectomy, 510 
Toxaemia, cause of headache, 342 
in pneumonia, 370 
Toxaemias pregnancy, 547 
Tracheal dilators, use of, 731 
Trachdtis, 366 
Tracheo-bronchitii, 367 
Tracheotomy, 730-1 
requisites 711, 730 
tube, inner, removd of, 731 
removal of, 731 

Traction, skdetal, 241 1 see also Extensions 
Trade dermatitis, 502 



INDEX 


845 


Tramfcr of patients, 28 
to another ho^ital, 29 
to another ward, 29 

Transfixion pin, use of, in extension, 

Transfusion of blood, 196 
Traumatic fever in fractures, 598 
Treacle enema, se$ Molasses, 131 
Tremor, 23 
Trench fever, afii 
Trcndclcnburg^s position, 88 
Trephining for glaucoma, 743 
the skull, 695 

Triangiilar bandage, 256-60 
Trigeminal neuralgia, 419 
Trinitrotoluene (T.N.T.), causing jaun- 
dice, 3Q2 
Trochisci, 298 

Trophic sores, prevention and treatment of, 
55 

Tropical dysentery, see Amoebic, 451 
Tubal gestation, 530, 551 
Tubercle bacillus, 482, 779 
lesion of infection, 780 
Tuberculin tests, 486 
Tuberculosis, bovine, 482 
miliary, 463 
of skin, see Lupus, 504 
pulmonary, 481 ; see also Pulmonary 
Tuberculosb 
sputum in, 65, 484, 489 
surgical, 779 
Tuberculous abscess, 780 
adenitis, 363 
enteritis, 779 
Tumours, 573 

573. 574 
ovanan, 534 
simple, 575, 574 
vaneties of, 573 
Tuning fork, 702, 721 
Turpentine enema, 131 
stupe, 91 

Tympanum, infiadon of, 702 
Typhoid fever, 4^ 
temperature in, 35 
state, ^6, 451 
Typhus fever, 459 

Ulcer, comeal, 747 
peptic, 379 
rodent, 789 

sublingual, in whooping cough, 475 
varieties of, 572 
Ulcerative c^tis, 385 
endocarditis, 349 
Umbilical hernia, 659 
Unconsciousness, dangers of, 754 
de^prees of, 754 
Undine, use oSf, 738, 746 
Undulant fever, 449 
Ux^enta, 298 
Uxma’s paste, use of, 104 
Upper motor neurone lesions, 407 
Uraemia, 401 


Uraemia, poet-operative, 647 
Urea concentration test, 213 
diuretic action of, 300 
Ureteric catheters, 137, 170 
catheterization, 140 
Urethra, foreign body in, 594 
Urethral catheters, 137, 170 
irrigation in gonorrhoea, 540-x 
Urethrotome, 677, 699 
Urethrotomy, 677 
internal, instruments for, 699 
Uric acid crystals in urine, 63 
excretion, 63, 262 
Urinals, cleansing of, 57 
method of giving, 56 
Urinary antiseptics, 299 
in pyelitis, 403 

tract, common symptoms of, 338 
infections of, 402 

Urine, amount of, in heart disease, 351 
catheter specimen of, observations on, 

, 139 

deposits in, 62 
examination of, 59 
in acute nephritis, 398 
in cystitis, 404 
in jaundice, 393 
in pneumonia, 371 
in pyelitis, 402 
incontinence of, 404 
normal, characteristics of, 58 
odour of, 58, 59 
reaction of, 59 
estimation of, 59 
residual, in hysterectomy, 515 
retention of, 405 

in fracture of spine, 603 
post-operative, 639 
specific gravity of, 58, 60 
estimation of, 60 
specimen of, on admission, 20 
sterile, 68 
c4-hours’, 68 

suppression of, in acute nephritis, 398 
tests fbr acetone in, 62 
albumin in, 60 
bile in, 61 
for blood in, 61 
diacetic acid in, 62 
phosphates in, 63 
protein in, 60 
sugar in, 62 
urates in, 63 

variations of, in dbease, 58 
in health, 58 

Urological system, investigation of, 402 
Urosclectan, use 189, 213 
Urticaria, 501 

Uterine applications of radium, 524, 

^525 

catheter, 137, 170 
Uterus, cancer of, 532 
curettage of, 509 
instruments for, 527 
pre- and post-operative care, 511 



imrnx 


846 

Uterus, dilatation of, instmmenta for, 537 
pre- and post-operative care, 51 1 
disorders of, 530 
displacements of, 531 
fibroids of, 532 
haemorrhage of, 570 
in pregnancy, 545 
prolapse of, 531 

Vaccination, 480 
scar, 480 
Vaccine, 326 
reactions to, 327 
therapy in gonorrhoea, 542 
Vaccinia, 480 

Vagina, examination of, 28, 516 
packing of, 518 
Vaginal discharges, 67 
nursing care in, 67 
observations on, 67 
douching, 143 
hysterectomy, 510, 513 
pre- and post-operative care, 513 
opK^rations, 509 

suppositories, see Pessaries, 518 
Vaginitis, 520 

Valvular disease of heart, 348 
symptoms of, 348 
Valvulitis, 348 
Van den Bcrgh reaction, 395 
Van Slyke’s test, 214 
Vaporcs, 298 

Vapour bath, application of, 1 14 
Vacpicz’s dis^e, 361 
Varicella, see Ghickenpox, 477 
Varicose veins, 356 

ulcers, use of Unna’s paste in, 104 
Variola, see Smallpox, 478 
Vegetables, 265 
Vein, affections of, 356 

taking blood from, requisites for, 70 
Venereal diseases, 535-42 
Venesection, 197 • 

requirites for, 198 
Venous bleeding, 569 
Vcntriculin in treatment of pernicious 
anaemia, 360 
Ventriculography, 210 
Vcntro-fixalion oi uterus, 510, 5x4 
pre- and post-operative care, 514 
Vermicides, use of, 430 
Vermin killer, poisoning by, 335 
Verminous head, treatment ot, requisites 
for, 50-2 

Vertebral column, deformities, 774 
Vesicants, 107 
Vesicle, defimtion of, 498 
Vina, 298 

Viscera, perforation of, 655 
Visceral syphilis, 537 
Visceroptosis, 391 
Visitors to infectious cases, 465 
Vitamin K, 290, 672, 804 
Vitamins, 290, ^4 
Volkmann’s contracture, 778 


Volkmann's ischaenuc oontracture, 598 
Vomit, coffee grounds, 65 
obs^ations on, 65 
specimen of, collection of, 69 
Vomited, blo^, 65, 380 
Vomiting, anaesthetic, 65, 640 
causes of, 65 

in epidemic diarxhoea, 386 
in infants, 66, 275 
in intestinal obstruction, 6^5 
in pregnancy, 545, 547 
in uraemia, 401 
nursing care in, 66 
post-operative, 640 
projectile, 66 
in infants, 66 
in pyloric stenosis, 390 
regurgitant, 655 
ruminating, 67 

Von Recklinghausen's disease, 436 
Vulva, toilet of, 517 
Vulvitis, 520 

Vulvovaginitis, see Vaginitis, 520 

War gases, 802 
Warm ba^, 1 16 
Wasserraann reaction, 538 
Wasting of infants, 276 
Watch-spring pessary, 522 
Water beds, storage of, 76 
uses of, 84 
pillows, uses of, 84 
uses of, 263 

vapour inhalations, 320 
Wax, application of, 104 
Weed-kUier poisoning, 334 
Weeping eczema, 502 
Weight, loss of, causes and treatment of, 
281-2 

of infants, observations on, 275 
record of, in tuberculosis, 490 
Weights and measures, 294 
metric system, 294 
Weil’s disease, 392 
Wertheim’s operation, 5x0, 5x4-16 
in cancer of uterus, 533 
instruments for, 528 
pre- and post-operative care, 515 
Wet cupping, no 
pack, XXX 

Wheal, definition of, 498 
Whey, preparation of, 266-7 
White leg, 554 

wine whey, preparation of, 267 
Whitehead’s varnish, use of, 653 
Whooping cough, 475 
Widal test, 449 
Winter cough, 368 
Wolfe's graft, 673 
Wolff’s bottle, use of, 3x0, 322 
Women, admission oi, 

Worms, 388 

Wounds, healing of, by first intention^ 
580 

by second intention, 581 



INDEX 


Wounds, infected, care of, 58a 
varieties of, 577 
Wright’s capsule, use of, 71 

Xerophthalmia, 290 
Xerosis, 804 

X-ray examination, 208-15 
See also under names of organs and regions 


X-ray treatment, 793 
reactions in, 794 

Yawning, 43 

Yellow ochre stools, 446 

Zinc protamine insulin, 439 
Zondek-Ascliheim test, 545 


847